Keywords

All of Italy’s specialist investigators into pellagra, or pellagrologists, shared a common experience as asylum doctors or directors in areas worst affected by the epidemic. Insane asylums offered a privileged site for observance of the disease, especially in its most serious and debilitating manifestations, on both dead and living patients. This shared asylum-based experience did not mean that Italian doctors were agreed as to the aetiology of pellagrous insanity, however. Poverty was clearly a predisposing factor but, as Cesare Vigna, director of the San Clemente asylum, noted, poverty was widespread across the world whereas pellagra was not. Vigna added: ‘Once all of the possible generating causes of pellagra have been gone through, the only unmissable one is this: the exclusive and insufficient peasant diet’ (Vigna 1879, p. 451; emphasis in the original).

At the time, explaining pellagra meant two main theoretical options, either dietary deficiency or toxin, as we saw in Chapter 4. On the one hand, Filippo Lussana, and later Clodomiro Bonfigli, director of the Ferrara asylum, theorised that a diet restricted to maize was lacking in nutrients essential for the body. On the other hand, Cesare Lombroso, one-time director of the insane ward at Pavia’s hospital, insisted that it was a toxin present in spoilt maize that caused pellagra. Along the lines suggested by Lombroso, Carlo Ceni—director of the scientific laboratory at the San Lazzaro asylum in Reggio Emilia from 1894—looked for the infectious toxin in the blood of the pellagrous patients (Ferrari 1985, p. 201). In addition to these two main theoretical camps—which could also co-exist in what Vigna called the ‘dualist’ position—there were a range of other explanatory factors which contemporaries considered variously important, from excessive alcohol consumption to heredity, from back-breaking labour to excessive exposure to the sun, as we saw in Part I.

To shed light on how the medical understanding of pellagrous insanity evolved during the second half of the nineteenth century, and to introduce the asylum experience of the disease explored in Chapters 8 and 9, we propose a comparison between pellagrous insanity and general paralysis of the insane—abbreviated as GPI and also known as paralytic dementia or general paresis, at the time, and today as tertiary or neurosyphilis. These two very different diseases actually had much in common. They shared an organic basis and severe mental symptoms in their final stage. They had a massive and virulent impact on their respective populations, contributing markedly to the increase in asylum populations in Italy and the UK. Just as importantly, they can be seen as paradigmatic expressions of the link between the physical and the mental, the somatic and the psychic, as it was conceptualised in the late nineteenth century. This view, especially where general paralysis was concerned, resulted in the idea that there might be a physical cause of all mental illness.

Not that this was perceived as straightforward. Vigna maintained that ‘aetiology is the most poetic branch of medicine … of all illnesses, mental illness offers the greatest aetiological complication’ (Vigna 1874, p. 34). And Vigna was not the first to make this metaphorical reference to poetry. John Bucknill and Daniel Tuke, in the first edition of their Manual of Psychological Medicine, likewise remarked that any attempt to define a mental illness was akin to defining poetry; any definition would be too narrow (Bucknill and Tuke 1858, p. 86). It might account for the apparent arbitrariness and discretionality that characterised the formulation of diagnoses in asylums (Shepherd 2014), in Britain as in Italy, as we shall see.

In 1871 E.T. Wilkins framed the question another way. Wilkins—‘commissioner in lunacy for the State of California’—opened his report on insanity and asylums with the question:

What is insanity? This question has been always asked but perhaps has never been satisfactorily answered, for the simple reasons that insanity assumes so many forms and differs so widely in different persons, that no definition can possibly embrace all of its phases. Many persons have given definition of this subtle malady but not one has met with that universal concurrence necessary to render it the true and only or even the generally received definition. … [David Skae] defined it ‘a disease of the brain affecting the mind’. We accept this definition as the best of all, because it is the most simple. It makes but little difference how the brain becomes diseased, whether primarily or by reflex action from the disease of some other organ of the body, so the fact as stated be true, that the brain must be diseased ere (before) the mind is affected. (Wilkins 1871, p. 8)

The passage highlights some fundamental and controversial epistemological matters pertaining to aetiology and the principle of causality in mental illnesses. It also raises the issue of the exact correlation between mind and body, psyche and soma, as crucial then as it is now. These topics were addressed by both the Italian debate on pellagrous insanity and the British debate on general paralysis. We shall explore how the two diseases were conceptualised in the wider context of contemporary psychiatric nosology and how the medical debate around them in Italy and Britain centred around analogous themes and topics, highlighting important epistemological questions of continuing relevance today.

Pellagrous Insanity and General Paralysis in the Late Nineteenth Century

It took Wilkins almost a year and a half to visit 149 asylums in sixteen European countries. His aim was ‘to collect and compile all accessible and reliable information as to their management, the different modes of treatment, and the statistics of insanity… a statement of the different modes of treatment in use and such statistics as he may deem reliable’ (Wilkins 1871, p. 1). In Italy, Wilkins visited fifteen asylums in all, including the Venetian asylum of San Servolo. And he was not the only foreign observer to take an interest in Italian asylums. Before and after him two Australian doctors also visited, Frederick Manning (1868) and George Tucker (1887).

We are thus dealing with three important publications of international reach, whose authors were considered amongst the most influential asylum doctors in their respective countries and abroad. These works reveal the intention of their authors to strengthen the medico-scientific status of asylum medicine, an intention they shared with many of their psychiatrist contemporaries. Scientific research trips were quite a common practice in the medical field at that time (Cagossi 1989; Cabras et al. 2006). The discussions and exchanges generated at an international level would broach issues such as commonly adopted treatments, the most recent advancements in the field of pharmaceutical remedies and procedures in asylums—fundamental questions for the development of the medical profession and the cognitive advancement of these early ‘alienists’.

Wilkins’ and Tucker’s studies are of great importance for understanding the Italian situation (Manning has little to say). Their standpoint seems to be less influenced by local Italian dynamics, the two authors being fundamentally extraneous to the reality that unfolded before their eyes. This allows for an implicit comparison between the many realities under observation. Indeed, they approached the European scene—specifically, the Italian and British ones—from an external and broad perspective.

According to Wilkins’ statistical tables, ‘pillagra’ (as he spells it) figures as the first cause of insanity in Italy, followed by ‘hereditary factors’ and ‘alcoholism’. These findings contrast with those gathered by Wilkins in other European countries, whereby ‘hereditary’ factors were considered by far the most prominent ones. Thus in England, Scotland and Ireland, heredity and alcoholism represented the main causal factors of mental illness. To these, according to Wilkins, one should add forms of domestic and existential distress, postpartum disorders and some other physical and mental diseases, including general paralysis—the latter representing the leading cause of death in England and Wales. If pellagra is judged the main cause of insanity in Italy, Wilkins offers no suggestion as to how a ‘cutaneous disease’ like pellagra might be linked to insanity (Wilkins 1871, p. 211).

For his part, Tucker visited eighteen Italian asylums, including the Venetian asylums of San Clemente and San Servolo, with which he ends the section of his report dedicated to the country. Based on interviews he carried out with the respective directors, Tucker informs us that the main cause of institutionalisation in Venice was pellagra for men (San Servolo) and pellagra coupled with hysteria for women (San Clemente) (Tucker 1887, pp. 1305–1310). In the United Kingdom, by contrast, the main triggers of mental disease were, in order of frequency: heredity, alcoholism, physical impairments, syphilis and deprivation. ‘Mania’, according to Tucker, was ‘as curable a disease as others’. By contrast—and endorsing the position of his colleague Dr. Savage from Bethlehem Hospital—‘general paralysis of the insane must still be looked upon as the one incurable and fatal form of insanity’ (Tucker 1887, p. 12). We shall return to this important point below.

Although the signs and symptoms of pellagra were, by this period, clearly recognisable, doctors faced continuing difficulties in explaining the aetiology and pathogenesis of the disease. The precise aetiology and pathogenesis of pellagra, and the role of nicotinic acid (niacin), was finally pinpointed in 1937 (see Chapter 3). But that left pellagrous insanity. Indeed, even now, ‘the exact relationship between niacin deficiency and the pathogenesis of psychotic symptoms’ remains unclear (Lopez et al. 2014). And yet experience taught contemporaries that patients suffering from pellagrous insanity could be saved if timely and adequately fed. General paralysis of the insane, by contrast, was not then regarded as curable.

General paralysis was first identified as a specific neuropsychiatric morbid condition in 1822 by the French physician Antoine-Laurent-Jessé Bayle (Bayle 1822, 1825). His formulations, made together with his thesis supervisor A.-A. Royer-Collard, were of major importance. Starting from the anatomopathological study on the meninges enveloping the brain and the spinal cord, the two physicians suggested the symptoms of ‘chronic frenzy’ manifest in general paralysis had to be differentiated from ‘idiopathic insanity’. The former was an epiphenomenon, a secondary symptom of an organic disease. As such, it was contrary to ‘idiopathic insanity’ and thus did not fall fully within the expertise of psychiatry (Postel and Quétel 2012, p. 204). General paralysis was a specific and peculiar disease for which thought disorders, speech impairment and psychomotor agitation were but manifestations. In 1894, Jean-Alfred Fournier established the syphilitic origin of general paralysis and introduced new methods of preventive care and public hygiene, to fight what he considered a spreading plague: syphilis (Fournier 1894). Over the next twenty years, Fritz Schaudinn and Erich Hoffmann and, later, Hideyo Ngouchi, would locate the morbid agent of progressive paralysis in Treponema pallidum of syphilis.

More broadly, both pellagra and general paralysis were societal diseases. They were directly linked to the major socio-economic transformations taking place in the nineteenth century. In Italy, the large-scale introduction of maize production and consumption in the northern Italian countryside, and the resulting transformation of land-holding patterns and dietary habits. In the UK—and in northern Europe more broadly—the processes of industrialisation, urbanisation and proletarianisation associated with the Victorian period, and the rampant phenomena of alcoholism and prostitution that these entailed. All of these factors played a significant role into turning general paralysis into what the pioneering Parisian psychiatrist Étienne Esquirol called ‘a disease of civilisation’ (1838, p. 400).

If pellagra and general paralysis had much in common, there were also significant differences. Whilst both diseases attacked people in their prime of life—35–50 years old—pellagra affected women more than men and was largely a feature of rural areas, whereas general paralysis struck men primarily and was characteristic of urban areas. That said, both diseases had severe repercussions for the life of the families affected by it in terms of the ability to work, as well as social stigma and moral condemnation. The latter were even more pronounced in the case of general paralysis. Whilst individual pellagrous insane might be regarded as either dangerous or a social nuisance, depending on how the illness manifested, pellagrous insanity as a whole was not generally regarded as a threat to the moral order of society. General paralysis, by contrast, was (Thompson 1988; Wallis 2015, 2017). When pellagra, and especially pellagrous insanity, impacted on the day-to-day functioning of family members, especially of the women, the social cohesion and ‘unity’ of the family were strongly undermined. Moreover, social stigma, which in most cases was generated by the very same family members, struck indiscriminately whoever had had a first-hand experience of the asylum. Thus, it was less pellagra as a disease than the experience of the asylum that created this social condemnation, as we shall see in the next two chapters.

At the time, and as we surveyed in Part I, medicine offered an array of representations of pellagra that are fluid, inconsistent and imprecise. Indeed, the medical and psychiatric debate around pellagra during the early nineteenth century was not centred solely on the aetiology and pathogenesis of the illness, but revolved around the essential nature of the condition. It called into question genetic, hereditary, domestic, climactic and geographic aspects, as well as cultural and moral ones. There were hypotheses of a correlation between pellagra and other diseases, such as leprosy and scurvy. That said, the ongoing investigation into pellagra’s symptoms failed to provide an answer regarding their status. Were they were symptoms or the actual disease itself?

During the second half of the nineteenth century, patients diagnosed as pellagrous insane at the two Venetian asylums amounted to just under a third of all inmates. They conditioned the functioning of asylums in maize-growing areas (a point we shall return to in Chapter 8). Similarly, in the UK, ‘the fate of GPI would in some ways mirror the fate of the asylums’, according to Juliet Hurn. General paralysis represented ‘an ever increasing proportion of asylum inpatients, and would reflect in its degrading course the expansion and progressive demoralisation of the asylum system’ (Hurn 1998, p. 17). That said, there was an important difference in the two forms of insanity, which must have impacted on how the asylums coped. Pellagrous insanity was curable, and was considered such at the time, if treated in its early stages before the illness became chronic. By contrast, the chronic degeneration wrought by general paralysis was regarded as inexorable (Shorter 1997, pp. 50–58). During their stays, general paralysis patients required constant supervision (Wallis 2015).

In terms of sheer numbers, at the Central London Sick Asylum, three-quarters of the interned suffered from ‘congenital’ or ‘acquired’ syphilis. Amongst the low- and middle-class male patients at Edinburgh’s Royal Asylum (Morningside), 40% were affected by alcoholism, syphilis or both. Amongst women, the figure was only 17%. Syphilis struck 22% of upper-class men, whereas none of the female patients of the same social origins at Morningside were affected by it. In Scotland as a whole, general paralysis was responsible for 14% of deaths in asylums, striking four times as many men as women (Thompson 1988, p. 318). In England and Wales, 18,438 patients affected by general paralysis were admitted into asylums during the period 1878–92—four to six as many men as women (Wallis 2015, p. 100). Andrew Scull estimates that, at the end of nineteenth century, almost one-fifth of men institutionalised in European and North-American asylums suffered from general paralysis (Scull 2015).

And numbers were the one thing contemporaries did have. At a time when the two diseases were still only partially understood, statistical methods were regarded as an important tool. In Venice, as elsewhere, the regular publication of statistical reports allowed for the spread of psychiatric knowledge and experience (Pelt 1847; Saccardo 1847; Salerio 1862). The attempt to raise the status of psychiatry as a discipline, through the gathering, analysis and classification of quantitative data, would lead, it was hoped, to a deeper understanding of mental diseases (Weiner 2008). If these statistical tools did not, in the end, contribute to a greater awareness of pellagra’s aetiology, they would play a fundamental role in the case of general paralysis.

Problematic Classifications: The Nosology and Aetiology of Mental Illness

Lodovico Pelt devoted the second part of his 1847 asylum report entirely to pellagra. The picture Pelt offers is telling: one-third of the population of the women’s asylum—still located in Venice—consisted of the pellagrous insane. All of the clinical cases discussed by Pelt in his report refer to such patients. Moreover, he recognised that the pellagrous insane referred to the asylum represented but ‘a small number of existing pellagrous patients’ (Pelt 1847).

Pelt described the development of pellagra in these terms:

Once developed, the disease threatens the body with physical devastation and, although it does not always lead to delirium, more often than not it does; which is when individuals are referred to central asylums. Acute malnutrition, weakness during labour, dry skin, pronounced dull grey endemic alteration of hands and feet with major or minor peeling of the cutis, frequent and intense sweating, fixed eyes, melancholic physiognomy, absent-mindedness: such is the sad clinical picture generally affecting a third of our patients. The prominent form of alienation is mania, followed by idiocy and severe dementia … after these, come melancholy and mostly religious mania. (Pelt 1847, pp. 91–92)

Pelt’s reference to ‘the prominent form of alienation’ is of particular relevance here, meaning the dominant clinical trait from a phenomenic point of view, necessary to begin the diagnostic process. This determines the fundamental classifications of mental disorders—mania, monomania, melancholia and so on—relating to the nature of the pellagrous patient. Through a simple process of juxtaposition and subsumption, it leads to the creation of hybrid forms of diagnosis (Berrios 2013). Apparently banal, this process does have its own internal logic and, as such, merits our attention.

Pelt devotes a whole chapter to the nature of mental diseases. His criteria are based on a double set of triggering factors: ‘predisposing’ (of hereditary nature), and ‘occasional’, necessary so that the former could become manifest in the form of a disease (Pelt 1847). The distinction between ‘predisposing’ and ‘occasional’ reflected a common practice in the medical field of the time (Davis 2008). ‘Occasional’ factors allowed the potential illness to develop and were determined by ‘physical’ and ‘moral’ factors, both acting ‘on the same individual at once’ (Pelt 1847, p. 54). Amongst occasional factors of a physical nature, alongside organic diseases—like scurvy, epilepsy, cerebrospinal disease, syphilis and muteness-deafness—Pelt also names pellagra. Amongst ‘moral’ factors, he lists ambition, love, avarice, heredity, marriage, misery, worries, fear and religion.

The distinction between ‘predisposing’ and ‘occasional’ factors, as well as that between ‘physical’ and ‘moral’ ones, would remain a point of reference in the aetiology of mental diseases in Venetian psychiatry for the rest of the nineteenth century. They were already widely used. Bayle had adopted them in distinguishing the causes of general paralysis into physical and moral, in turn divided into predisposing and occasional. For Bayle, predisposing moral factors were as incisive as physical ones (Bayle 1826, pp. 402–4; Postel and Quétel 2012).

Pellagra features in Pelt’s classificatory system as one of the possible ‘factors of physical origin’. The adjectival label ‘pellagrous’ was associated with a sign, symptom or syndrome—whether mania, monomania, melancholia, dementia or idiocy. It followed, then, that Pelt stressed the correlation between these and a specific ‘physical factor of occasional nature’, i.e. pellagra (Pelt 1847). Indeed, the diagnoses frequently attributed to pellagrous patients were ‘pellagrous frenzy’, ‘pellagrous melancholia’ or ‘melancholia due to pellagra’, ‘mania due to pellagra’ and ‘pellagrous monomania’ (see also Chapter 8). These diagnoses suggest the dual status pellagra had at the time: on the one hand, hypothesised as a cause, or contributory cause, of mental disorder, and on the other, as a disease whose nature remained fundamentally unknown. Curiously, this meant that pellagra was confidently identified as the cause of manias even whilst the exact causes of pellagra itself remained unknown.

The severe psychiatric symptomatology and the often shocking behaviour exhibited by pellagrous patients were due to inexplicable psycho-neuroendocrine and metabolic processes, which led generations of doctors after Pelt to adopt a merely empirical, descriptive and symptomatic model. They simply transferred and expanded diagnostic classifications from patients affected by ‘manias’ on to pellagrous patients, adding the label ‘pellagrous’ to the diagnoses already in use. Despite insights offered by the field of anatomical pathology into the nature of pellagra (Labus 1847), the fundamental problem concerning the understanding of pellagra’s psychiatric symptoms and their diagnostic translation would linger throughout the nineteenth century.

A similar issue was present in general paralysis (Davis 2008). At the Hanwell Asylum in Middlesex, for instance, it was reported as a distinct diagnosis from 1870. However, from 1880, following the introduction of a standardised clinical file format, ‘the diagnosis was again practically always given as [insanity type] + general paralysis: a style which equivocally suggested a complication’ (Hurn 1998, p. 46). Whereas Hurn tends to attribute such discrepancy between theory and clinical practice to the difficulties related to the everyday running of the asylum, Germán Berrios and Roy Porter suggest that theoretical boundaries between nosographic categories were not clear-cut (Berrios and Porter 1995). Let us try to shed some light on this contradiction.

In the first edition of their Manual of Psychological Medicine, published in 1858, John Bucknill and Daniel Tuke argued for the need to present a ‘more comprehensive’ classification of mental diseases than the traditional nomenclature of Esquirol, without rejecting it entirely. Their classification consisted of five fundamental categories: idiocy, dementia, delirious and emotional insanity and mania. General paralysis, the triggering factors of which were imputable to alcohol abuse, misfortune, domestic problems and libertinism, could complicate these forms (Bucknil and Tuke 1858). The two alienists thus assigned a character of ‘complication’ to general paralysis: its consequent and peripherical nature in contrast to the dominant psychopathological picture. This was confirmed in the 1862 edition of their Manual. However, they also noted that ‘the reasons for regarding General Paralysis as a distinct form of insanity possess much greater weight’ (Bucknill and Tuke 1862, p. 89). Whereas the adjective ‘pellagrous’ referred to a specific order of alleged causes, in the diagnosis of general paralysis its status remained that of a complication.

The most frequent causes of general paralysis referred to emotional disorders of various sorts, such as anxiety and jealousy, but also included heredity, fever, head injuries or the manifestation of diseases to which general paralysis was the culmination. At the same time, the authors maintained, the disease ‘is very frequently caused by intemperate habits’ (Bucknill and Tuke 1862, p. 496). They suggested that general paralysis might also be a consequence of ‘a disease of nutrition affecting the whole nervous system’. This idea was based on the overall malfunctioning of the neuro-muscular system and on the numerous and suspect instances of fractures and even deaths due to patient falls (Wallis 2013). The idea of a possible dietary cause of general paralysis suggests a further affinity with pellagra—although one that did not actually exist. At any rate, the two doctors were forced to conclude that ‘the pathology of this disease is yet purely a matter of surmise’ (Bucknill and Tuke 1862, p. 495).

In 1871 the London doctor G. Fielding Blandford went further, seeing general paralysis as a distinct, ‘well defined, recognisable’ disease. It was fatal, with a rapid course, immune to any treatment, whose causes lay in sexual excesses. At the same time, Blandford was forced to admit that when it came to ‘the pathology and nature of the disease, there are still great doubt and controversy’ (Blandford 1871, p. 256). Its origins remained unknown and highly controversial.

Bucknill and Tuke’s 1879 edition of the Manual represents a significant change in the psychopathological picture as a whole. With the traditional paradigm of organ-based medicine in mind, they suggested the existence of ‘typical psychopathological forms’—‘distinct mental diseases originating in different bodily causes, pursuing a definite course, and having a distinctive morbid anatomy’ (Bucknill and Tuke 1879, p. 51). It was necessary to distinguish the morbid forms starting with their evident characteristics, rather than their supposed intrinsic nature. Similarities, affinities, characteristics, external properties and physical conditions: these would henceforth be the criteria on which the categorisation of mental diseases would be based. They advanced a classification based on three macro areas of disease: (i) ‘protopathic insanity’, or mental deficiency, which included illnesses due to primary factors and insufficient development, such as idiocy and general paralysis; (ii) ‘deuteropathic insanity’, due to the development of organs independent of the encephalic centres, which included puerperal insanity; and (iii) ‘toxic insanity’, deriving from various forms of intoxication or poisoning, which included alcoholism and ‘pellagrous insanity’. When it came to this neat classification, general paralysis put the two doctors into a bit of a quandary, since it ‘sometimes is and sometimes is not caused by excess of alcohol’. And they admitted that no classificatory system was ‘free from objection and more or less obvious inconsistency’ (Bucknill and Tuke 1879, p. 53).

Medical authors writing in their wake stressed the difficulties in diagnosis, despite the vast spread of the disease. It still risked being mistakenly diagnosed, especially during its early stages (Mickle 1886; Berkley 1901). The ‘typical psychopathological forms’ advocated by Bucknill and Tuke were not easily applied to clinical practice and translated into diagnostic expression. It was impossible to establish sufficiently clear links and theoretical connections with other forms of the same illness and with other psychopathological profiles. Furthermore, even when isolated at a descriptive level, general paralysis could appear in spurious, fluid and fluctuating modalities in clinical practice, whose translation into diagnosis was not straightforward.

This would explain the widespread use of rhetorical labels like ‘pseudo’ and ‘diathesis’ (predisposition), used with reference to both general paralysis and pellagra. In this sense, ‘a classification system based on external symptoms that tended to vary in the extreme’ (Grob 2008, p. 541), could lead to merely descriptive or formalistic diagnoses, empty of explanatory and cognitive content. The essential characteristics of general paralysis and pellagra may have been clearly understood and recognised at a conceptual level, but serious difficulties remained in translating this knowledge into diagnostic reality.

The Physicality of Mental Illness?

The use of statistical analysis seemed to suggest a way forward in the case of general paralysis. This transition from qualitative to quantitative was behind the significant conceptual reformulation originated by Jean-Alfred Fournier. The French venereologist radically modified his point of view on the link between syphilis and GPI precisely on account of statistical evidence. Fournier maintained that ‘general paralysis is not a disease of a syphilitic nature; we simply believe and simply call it of syphilitic origin: a syphilitic diathesis to which the term “parasyphilitic” can be attributed’ (Fournier 1894, p. 191; emphasis in the original). He observed that, on average, between 60 and 80% of patients affected by progressive paralysis had previously manifested episodes of syphilis. For Fournier, this could not be a mere coincidence. The impairments associated with general paralysis could be caused by syphilis, ‘since both aetiology and clinical studies teach us that very often general paralysis is of syphilitic origin’ (Fournier 1894, p. 194).

Numbers thus allowed investigators to shed light on new, distinct clinical findings. The research conducted by Fournier into the origins of general paralysis introduced a variance between the direct observation of the patient and quantitative representation as provided by numbers. We noted above how the statistical tools used in Venetian asylums, as applied to the pellagra, were in line with clinical observation; the two methods of observation perfectly complemented and legitimated one another. By contrast, when it came to research into general paralysis, these tools suggested a conflict, since the results provided by the two procedures were qualitatively different. Statistical tools seemed to offer a viewpoint that was at once distancing and objectifying, lacking the all-too-human and relational implications that characterised direct contact with the sufferer. The approach came to the fore in debates over pellagra’s aetiology, explored in Chapter 3. Here, the strictly positivistic and laboratory-based approach epitomised by Cesare Lombroso faced down the more traditional clinical methodology, characterised by a direct contact with the patient, evident in the work of Clodomiro Bonfigli.

With regard to developments into the origins of general paralysis, there was an increasing tendency in the UK to look for evidence of previous syphilis in the case history of patients suspected of general paralysis. Whenever the presence of syphilis in the patient’s history was confirmed, the correlation with general paralysis was direct. Nonetheless, this association would prove unclear for many years to come. As with pellagra, general paralysis remained enigmatic in the way it appeared ‘to reveal something of the processes occurring deep within body and brain’ (Wallis 2015, p. 102). The recognition of a syphilis—general paralysis link did not immediately lead to any clarification in the actual nature of the disease and the correlation between the two afflictions. Especially after the discovery that general paralysis coincided with third-stage syphilis, general paralysis acquired a coherent profile in line with an essentially organic, chronic-degenerative understanding of mental pathologies. Indeed, for British alienists, general paralysis came to represent the most recognisable, structured and solid amongst disease entities, one that was able to provide psychiatry and psychiatric practitioners with a stable physicalist and organicist foundation (Hurn 1998). It offered an ideal and seductive model of rationality to British psychiatry, which hoped to discover in the obscure syphilis-general paralysis link the same mechanisms generating mental illness in general.

By contrast, an analogous reading of pellagra as a paradigm of the cerebral rootedness of mental diseases is more difficult. A series of elements made the pellagrous pathology less appealing (including at the symbolic and imaginary level). Take, for instance, the cutaneous symptoms in pellagra. Whereas the physical symptoms of general paralysis recalled a possible direct correlation of the disease with a deficit of the central nervous system, the simultaneous presence of cutaneous and mental symptoms typical of pellagra were less easily deciphered. Furthermore, pellagrous insanity was curable under certain circumstances. Many doctors held the idea, gradually supported by the facts, that pellagra constituted a pathological entity in its own right independent of its mental symptoms. Finally, the geographical localisation of the disease within a fairly precise geographical delimitation—essentially north-eastern Italy—did not permit arbitrary generalisations. These characteristics clearly distinguished pellagrous insanity from general paralysis, making the disease of Italian peasants less amenable to the explanatory and naturalistic model adopted by psychiatry in the UK.

Enduring Diagnostic Challenges

In 1862 the director of San Servolo, Prosdocimo Salerio (1815–77), bemoaned the limitations of contemporary classification and nomenclature when it came to mental disease, wishing for one that was ‘more rational, more in line with the nature of these diseases’ (Salerio 1862, p. 8). Later, he maintained that we might see the facts but were unable to account for them. For instance, with regard to heredity as a pre-existing, cerebral cause of pellagrous insanity, Salerio noted how it ‘remains an uncharted area; we still are shrouded in a dark fog’ (Salerio 1871, p. 19).

Salerio expressed his doubts this way:

The classification of mental diseases based on pathological and anatomical alterations relies on tentative, a posteriori diagnoses. How many times the alleged diseases prove to be unfounded! It is said they should be like this, that the alterations cannot always be understood but which must exist. Moreover, how is it that the same alterations manifest themselves always in the same way? Is there a constant relation among them? Can we always give them the same interpretations? Are these [brain] lesions a constant in this specific form of mania? I think that, thus far, we can only ever claim this for pellagra and general paralysis. Sometimes only conjecture is made and, more often than not, doubts arise as to whether these lesions are the cause or the effect of the actual insanity. Do different causes always produce the same manifestations? Why, then, do different manifestations replace and follow one another in the same individual? (Salerio 1871, p. 3)

Salerio’s position recalls that adopted towards the end of the century by the German clinical psychiatrist Emil Kraepelin (1856–1926). Kraepelin ‘[admitted] his delusion in the face of the extremely inadequate therapeutic possibilities and diagnostic correlations that he [found] baffling’ (Hoff 1989, p. 46). In his memoirs, Kraepelin wrote of the ‘impotence of medical action that most of the time had to limit itself to pleasantries and summary physical cures’, as well as ‘the utter dismay faced with all these manifestations of insanity, beyond any scientific explanation’ (Kraepelin 1989, p. 28). He demanded that nosological formulations be constantly subjected to clinical practice, a practical scepticism that also characterises this phase of Venetian psychiatry.

In the writings of Venetian asylum directors and alienists like Salerio—as in Pelt before him and Vigna and Dalmazio Battanoli after him—it is not unusual to find references to the inadequacy and arbitrariness of the disease categories and diagnostic labels of the time. Their thinking was characterised by a sort of epistemological humility. They expressed the inadequacy of their theoretical apparatus, just as Bucknill and Tuke did, and were aware that it could account for the complex and multifaceted manifestations of mental illness. This had the effect of complicating the doctor-patient encounter, making the diagnostic process problematic and uncertain.

Salerio’s words could have been written at any time in the second half of the nineteenth century. Indeed, they have an uncanny currency today. They resonate with the considerations formulated, almost a century and a half later, by the US psychiatrist Allen Frances, director of the task force that compiled the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV):

Descriptive classification in psychiatry has so far been singularly unsuccessful in promoting a breakthrough discovery of the causes of mental disorder. [Although] the miraculous advances in our understanding of normal brain functioning, [the] impact on understanding psychopathology almost nil … Any given type of pathological functioning can have many different causes … Psychopathology is heterogeneous and overlapping not only in its presentation, but also in its pathogenesis… Indeed, the concept of mental disorder is so amorphous, protean, and heterogeneous, that it inherently defies definition. This is a hole at the center of psychiatric classification. (Frances 2010, p. 22)

The ways in which pellagra and general paralysis were conceptualised during the second half of the nineteenth century suggest an underlying tension. On the one hand, we can observe a need to isolate, create and fix a scientific object, beginning with its stable representation. On the other hand, that very same object remained elusive, fleeting and unformed—whose real manifestations eluded the taxonomical grasp. The two diseases, at different levels, proved to be difficult to classify, whether amongst organic diseases or amongst specifically mental disorders. Their status remained dubious and undefined, resembling a sort of two-faced Janus with one face looking towards soma and the other towards psyche.

Our analysis of the diagnostic rationale behind pellagra and general paralysis has allowed us to stress the limitations of diagnostic formulations in use amongst alienists in the second half of the nineteenth century. Although pellagra and general paralysis were acknowledged as specific and distinct clinical entities, they nevertheless lacked a recognised and precise aetiology and pathogenesis. As a result, the diagnostic process gave room to doubts, uncertainties and questions. The obscurity of the disease-causing processes could result in diagnoses that were weak in heuristic terms and less than useful in terms of actual treatment. Analogous problems resurface in contemporary psychiatry, to be sure, although to a different degree. By tracing the histories of pellagra and general paralysis, we have sought to offer historical and conceptual evidence of the need to subject ‘diagnostic reason’ to constant criticism, something of which our asylum doctors were only too well aware. How this translated into the treatment of pellagrous patients in the asylum is the subject of the final two chapters.