Keywords

In practice, there were two possible outcomes for the patients of San Servolo and San Clemente: discharge or death. And this is how their patient records are filed in the archives: usciti or morti. Most of the pellagrous insane left the asylums either ‘cured’ or, like Maria Poloni, merely ‘improved’. But if their physical and mental condition worsened whilst in the asylum, then death was often the result. By way of conclusion, in this chapter we examine the final stage in the life cycle of pellagrous patients.

Women were more likely to die in the asylum than men: 43% of the female pellagrous insane at San Clemente died, compared to 32% of pellagrous men at San Servolo. This may be due in part to the overcrowding at San Clemente, especially in its early years, when it was virtually overwhelmed. That said, the same gender difference is evident in other maize-growing/consuming areas. At San Lazzaro in Reggio Emilia, mortality rates for the pellagrous insane during the period 1884–1899 were 47% for women and 33% for men. At the Mombello asylum in Milan, mortality rates were likewise worse for women than men (Ferrari 1985, p. 190; Ferrari 1984, p. 100). As we observed elsewhere in this book—and as was appreciated at the time—not only did pellagra and pellagrous insanity affect women more than men, women were also more likely to die in the asylum because of it.

The most common cause of death in the asylum was closely associated with pellagra itself: the chronic diarrhoea that accompanied pellagrins virtually from the onset of the disease (Lombroso 1868, pp. 32, 33). The medicinal treatment recommended by Lombroso in such cases, calomel or mercurous chloride, was widely used at the time for its potent purgative properties. Towards the end of the century, the then-director Ernesto Bonvecchiato attempted other therapies at San Clemente, such as applying ice bags to the abdomen or electrical currents. However, he had to admit that nothing was really effective against these ‘for the most part incessant diarrhoeas, resistant to every cure’ (Bonvecchiato 1899, pp. 37–38). And indeed in our two asylums combined gastrointestinal and related wasting diseases, including cachexy and consumption, accounted for almost half of all deaths (47%) amongst the pellagrous insane. Lung infections, to which bodies weakened by pellagra were prey, compounded by overcrowding and lack of adequate heating in the asylums, accounted for another fifth (21%). These were more pronounced amongst the women at San Clemente than men at San Servolo (28% compared to 13%). By contrast, infectious diseases such as smallpox, typhus and cholera were relatively rare (2%).

A final cause of death was suicide. Indeed, the very real danger the pellagrous insane posed to themselves was often cited as the many reason for their referral in the first place (Salerio 1871, pp. 20–22). According to Italian government statistics, 145 pellagrins committed suicide in 1874, a year in which 945 pellagrous insane were admitted to asylums (MAIC 1879, p. 36). Actual rates of suicide in asylums may never be known. The following case explains why.

When 49-year-old Angelica Pontoni was referred to San Clemente from Udine’s civic hospital in February 1877, she had been suffering from pellagra and recurrent diarrhoea for six to eight years and was already a known suicide risk. After trying to kill herself by throwing herself in a pool of water on 26 July, three days later Angelica finally succeeded, somehow undoing the straightjacket in which she was confined and using the laces to hang herself from the bars of her window. When Dr Brunetta was called to the scene, her body was still warm, but despite various attempts to reanimate Angelica, she was pronounced dead. However, the case did not end there. When it came to entering the cause of death, Brunetta opted for ‘brain congestions’ (i.e. stroke). Evidently, he sought to avoid accusations of neglect or worse. A few days later, magistrates in Venice investigated the case, when they became aware of the discrepancy between the two versions of events. They warned director Vigna to be more precise in future to avoid legal proceedings.

Fortunately, the majority of pellagrous patients ended their asylum confinement on a happier note, discharged and returned home. This was due to the relative curability of pellagrous insanity, referred to in the previous two chapters. Eight out of ten of the female pellagrous insane who returned home did so either ‘cured’ (guarita) or ‘improved’ (migliorata), according to indications made on their patient files. This compares to only six out of ten of the non-pellagrous insane. The condition of patients upon discharge generally went unrecorded at San Servolo, but the proportions of ‘cured’, ‘improved’ and ‘not improved’ pellagrous patients upon discharge were probably similar to other Italian asylums, such as Como’s San Martino asylum (Giudice 2009, p. 80).

The distinction between ‘cured’ and ‘improved’ may seem subtle, but it is an important one—and indication of the limitations in what the asylums could achieve when it came to the treatment of pellagrous insanity (and indeed insanity more generally). Moreover, the case of Maria Poloni, whose health was pronounced as ‘improved’ (migliorata) upon her release—as we explored in the previous chapter—suggests that various financial and family pressures might conspire to necessitate an early release.

Finally, one out ten pellagrous insane women left San Clemente ‘not improved’ (non migliorata). These were generally chronic cases, presumed non-threatening and manageable in other contexts, whether domestic or institutional. For instance, some female insane were transferred from San Clemente to other hospitals: this is what happened to Francesca Canale, as we shall see below. This transferral of the pellagrous insane to other local institutions occurred much less often than that of the non-pellagrous insane (8% compared to 28%)—suggesting perhaps that the local authorities were reluctant to take the pellagrous cases on if they did not have to.

How were the approximately two-thirds of pellagrous patients who were discharged from San Servolo and San Clemente reintegrated into their communities of origin? This was often the weak link, another limitation in society’s response to pellagrous insanity—and indeed to pellagra in general. First of all, there was the social stigma that former patients might suffer by having spent time in the asylum. A fisherman from Chioggia, Antonio Chiereghin, found himself continually taunted with ‘matto di San Servolo!’ (San Servolo lunatic!) as he walked through the streets following his return to his native island in the Venetian lagoon. Fed up, Antonio sought a meeting with the local magistrate. This was finally granted, but when the magistrate told Antonio to leave, the former patient started shouting that although the law was supposed to be the same for all, he was not treated like other people. Antonio was forcibly detained by the carabinieri who took him to the local hospital and thence again to San Servolo, where he died of pleurisy in October 1883.

Community reintegration was complicated by a second factor. Pellagrous insanity might be curable—at least before it became chronic—but once former patients went back to their previous lives and their subsistence diet of maize polenta, there was a risk that the insanity would return. And the asylum doctors knew it. Thus the final words on Emilio Beggiato’s patient file from 1880: ‘Unfortunately, since he is returning to poverty, sooner or later we shall see him again’.

A glance through the patient files suggests that repeat admissions were not uncommon. Giacinto Bego, referred to San Servolo from the municipal hospital of Adria for ‘mental hallucination due to pellagra’ at the end of March 1871, was pronounced cured three months later. Six years later Giacinto was back, ‘for attacks of mania and for attempting to drown himself and kill his children’. He told the asylum doctor that this was his third admission to San Servolo—in fact it was his second. Within weeks Giacinto’s physical condition had improved and he was sent to work in the vegetable garden; by July his mental faculties had returned and by August he was ready to be discharged.

The reality is at its most strikingly apparent in the case of Francesca Canale. She was a 39-year-old peasant woman from Lugo Vicentino (province of Vicenza) when she was first admitted to San Clemente in April 1881 with ‘pellagrous insanity’. Francesca was discharged, ‘cured’, fifteen months later, a longer stay than was usual. And indeed she would be re-admitted to San Clemente on no less than four occasions over the following ten years. Her patient photographs track these re-admissions, a maturity spent dealing with pellagra and its recurrent effects (Fig. 9.1). Her final patient file, relative to her admission in 1892, has no photograph attached; and yet she remained at San Clemente for four more years, before she was finally transferred to the civic hospital at Noventa Vicentina, closer to home.

Fig. 9.1
4 photographs of Francesca Canale taken between 1881 and 1889.

Successive photographs from four of Francesca Canale’s patient files, 1881–1889. San Servolo Servizi Metropolitani di Venezia

Full size image

Given that the historian’s gaze is naturally drawn to the dramatic examples of repeat admittances like these, we should not overstate the phenomenon. At San Servolo, 15% of pellagrous men were admitted more than once; whilst at San Clemente, only 5% of pellagrous women were re-admitted. This is significantly lower than the re-admittance rate for non-pellagrous patients at San Clemente, which is 14%. It is also lower than the rate at other Italian asylums where pellagra was endemic. At San Lazzaro, in Reggio Emilia, during the years 1881–1896, over a quarter (27%) of pellagrous patients were re-admitted; and the rate was higher still at Mombello in Milan, where two-fifths (40%) of patients were re-admitted (Ferrari 1984, p. 192; Ferrari 1985, p. 104). The difference is difficult to account for. Perhaps it was down to a combination of overcrowding at San Clemente and the funding mechanism by which specific bed numbers were assigned to each of the provinces of the Veneto, which may have resulted in a preference for first-time patients over repeat admissions.

To us today, the location of Venice’s two former asylums of San Servolo and San Clemente, on adjacent islands in the lagoon, with beautiful views of Venice, is calming and picturesque. San Servolo serves as a conference centre, university teaching facility, wedding venue and archives (where the two of us spent many fulfilling hours). San Clemente is a ‘five-star urban luxury resort’ (according to its website). And yet they must have seemed forbidding and frightening to the pellagrous insane, most of whom had never been near the sea before, as they were rowed over to the islands on small boats (Salviato 2002, p. 910). This double degree of separation—both from the mainland and from the city of Venice itself—emphasised their ‘otherness’ as spaces and their custodial role as tools of ‘social control’ and segregation of the insane, regarded as threatening dangerous.

But the asylums were not prisons. They also aimed to treat and cure: through diet, medicines and work-related activities. This treatment focused more on dealing with the manifestations and symptoms of madness and less on its underlying causes. The result was that, despite the high numbers of pellagrous insane admitted to San Servolo and San Clemente, they were not separated from the general ranks of the insane or treated any differently from them. As it turned out, this emphasis on the physicality of insanity particularly lent itself to the treatment of pellagrous insanity, which responded well to the better diet and living conditions the asylums offered.

Because experience taught that pellagrous insanity was often curable, the two Venetian asylums were not places of no return. Instead, they functioned as revolving-door institutions: in both the positive sense of regularly and routinely discharging cured patients, as well as in the negative sense of re-admissions, when the pellagrous insanity struck again. The asylums may have been out of the way, but, with their daily ferry service, ‘half-an-hour’s pull by gondola from Venice, and in full view of that city’ (Tucker 1887, p. 1305), they were not cut off. The asylums lived in close symbiosis with their territory, which extended beyond the city and province of Venice to include the entire Veneto region (and sometimes beyond), forming part of a network of care. They functioned as both tools of segregation, removing the insane from the rest of the population, and integration, as they were restored to their communities, if and when they were pronounced cured.

Epilogue

This discussion on leaving the asylum seems a fitting moment to bring this book to a close. With limited direct medical intervention to eradicate the disease, pellagra in Italy continued to decline, on its own, in the years leading up to World War I, until there were virtually no new cases. On 26 May 1927, celebrating the five years of the Fascist regime, Benito Mussolini triumphantly proclaimed that ‘the Italian nation has definitely won this battle [against pellagra]’. Mussolini had reason to feel smug: not only had he recently proclaimed himself duce, and as such was no longer answerable to parliament, but the official end of pellagra came at a time when cases of the disease were still skyrocketing in the United States. The disease seemed to appear from nothing in the southern U.S. in the early 1900s, so fast indeed that it was regarded as an infectious disease, as we saw in Chapter 4.

The US medical authorities soon took up the cause, even whilst medical interest in Italy waned. The tireless Joseph Goldberger, a medical officer for the newly founded US Public Health Service, became convinced of the link between income (low), individual diet—not polenta but corn meal, fatback, molasses—and pellagra. Goldberger was still seeking to identify what he called the ‘pellagra preventive factor’ when he died in 1929. By the time a deficiency of nicotinic acid (niacin) was identified as the cause, in 1937, pellagra had declined in the U.S. South. And, as in Italy, this was due more to socio-economic changes—in the American case the result of an invasion of boll weevils that destroyed the cotton fields and forced landowners and farmers to diversify their crops—than it was to medical and government action.

In 1909, the US journalist and educator Marion H. Carter asked à propos of pellagra: ‘why must a sentient human being suffer this?’ (Carter 1909, p. 94). It was as good a question then as it is now. In Italy, over the course of the long nineteenth century, Mattio Lovat and thousands of other pellagrins and pellagrous insane suffered the torments of (and often died from) what was essentially a man-made or anthropogenic disease which societal conditions and structures allowed to spread. The relationship between maize subsistence and pellagra was evident from the 1760s, as was the poverty lying behind both. And yet the Italian social and mercantile elites, national governments and large parts of the medical profession—albeit with some notable exceptions—were wary of undertaking anything but cosmetic measures, worried by the threat to the existing social structure and vested interests that more radical solutions posed.

Pellagra is just one in a list of diseases which not only caused untold suffering, but which were preventable according to the medical standards and knowledge of the time—that is, the latter half of the nineteenth century. These included two other deficiency diseases: beriberi in Japan, caused by eating processed rice (Carpenter 2000; Bay 2012), and goitre in parts of Spain, due to an iodine deficiency (Fernandez 1990).

Man-made epidemics are not confined to the past, however. Think of the dramatic rise in obesity and associated chronic diseases like diabetes in our own society. Caused in part by an energy-rich but nutrient-poor diet of fast food and fizzy drinks, the tussle between health experts, governments, the food industry and the wider society has only just begun. Like the maize-based diet that led to the pellagra epidemic, a human diet today that is energy dense and nutrient poor has led to a pandemic of obesity, diabetes and associated chronic diseases. Then, as now, a shortage of food is not the problem. If we superimpose a map of obesity rates in the United States today on to a map of the pellagra epidemic there during the first three decades of the twentieth century, it is a shockingly close fit (Marks 2003, p. 39; Masnick 2011). Without wishing to oversimplify a complex situation, poverty is the main contributing factor in both. Today, people on low incomes are likely to buy food that is bad for them; only the better off can afford to make healthy and ethical choices, which the food industry encourages and to which governments acquiesce, under the banner of offering choice.

Just as ‘scientific nutritionism’ is being increasingly blamed today for blinkering us away from available healthy foods, to the benefit of the food industry (Scrinis 2015), so in the past medical science seemed to collude with national governments in ensuring that campaigns against pellagra did not attack maize-production interests. In Italy, in 1910, the maize-producing city of Bergamo welcomed Louis Sambon’s theory of an insect aetiology for pellagra, because it let maize of the hook and protected their milling industry. And in the United States, once it was realised that niacin could prevent pellagra, it was more beneficial to all simply to adopt niacin as a food supplement rather than address the deeper issues of deprivation behind the disease. Current debates, such as that over biofortification of staple foods as against dietary diversification in the developing world, run much deeper than is generally assumed.

Finally, as we write, the media abounds with claims about the link between nutrition and mental health. Apparently, a Mediterranean diet can stave off depression. It would seem that a cure for even neuropsychiatric conditions like epilepsy, attention deficit hyperactivity disorder and autism is only a well-balanced diet away. There seems no denying that food intake and food quality should impact brain function, and yet the science and evidence base of these claims remains much debated (Adan et al. 2019). It is salutary to be reminded that a clearly documented link between one particular diet and mental illness already exists: pellagra. The ‘randomised control trial’ for it lasted over a hundred and fifty years, involved many hundreds of thousands of victims across the world, and resulted in terrible suffering and misery.