The Conquest of Pellagra
27 April 2005
The conquest of pellagra is commonly associated with a single name, that of Joseph Goldberger (1874-1929) of the United States Public Health Service. The story, as it is usually told, is that in 1914 Goldberger was assigned to the growing problem of pellagra in the Southeastern United States; that pellagra was then commonly thought to be an infectious disease; that Goldberger proved the cause to be dietary deficiency; and that through relentless campaigning Goldberger spearheaded the effort to eradicate pellagra as a public health problem. Goldberger rightfully deserves a place in the pantheon of giants in the history of medicine and public health. However, the standard version of pellagra shortchanges the contributions of many other workers and tends to overlook the fact that Goldberger’s involvement with pellagra came at a propitious moment, when the possibility of a specific dietary deficiency and indeed a vitamin deficiency had already been posited.
In 1907, pellagra was first recognized to be an endemic problem in the United States by George H. Searcy and his colleagues at the Alabama Institute for Negroes in Mount Vernon, Alabama, wh o reported 88 cases with 57 deaths. Shortly thereafter and independently, James Woods Babcock (1856-1922), director of the South Carolina State Hospital for the Insane, likewise recognized the disease and traveled to Italy, where he confirmed pellagra was in the United States was the same as pellagra seen there. Babcock convened, and was elected president, of a National Association for the Study of Pellagra, which came to involve the efforts of numerous physicians and public health workers throughout the United States. Babcock is commonly credited with doing more than anyone else to publicize pellagra as a public health problem throughout the United States, especially in asylums and in disadvantaged populations such as textile workers and African-Americans. In 1914, Babcock resigned from his governmental appointment in the wake of an attack by the governor of South Carolina, who was a blatant white supremacist and a vicious politician. Thus, there was little or no overlap between the “Babcock era” (1907-1914) and the “Goldberger era” (1914-1929), although Babcock was present when Goldberger announced his findings in 1915. Why did Babcock and his colleagues fail to pinpoint the etiology? How close did they come?
Commonly known as the “disease of the four D’s—dermatitis, diarrhea, dementia, and death"—pellagra is now attributed to deficiency of nicotinic acid (niacin). In 1735, it was first recognized in Spain as mal de la Rosa. I n 1771 it was recognized in Italy by Francisco Frapolli and given its name, from pelle (skin) and agra (rough) on the basis of the characteristic rash (which can resemble a second- or third-degree burn) in sun-exposed areas. In 1810, another Italian, Giovanni Battista Marzari, proposed that the disease was caused by over-reliance on corn as the main dietary staple, and that corn was deficient in “gluten.” This proposal gave rise to two schools of thought: the Zeists, who supported the corn theory, and the anti-Zeists, who discredited it. Then and subsequently, various people, beginning with Théophile Roussel in France (1848), proposed that pellagra could be prevented by a change in diet. Moreover, most physicians who treated pellagra (including, later, James Woods Babcock and his contemporaries) routinely advised a liberal diet as part of the regimen. However, a split emerged among the Zeists when it was proposed the central problem was not over reliance on corn but rather the consumption of spoiled corn. This latter viewpoint gained ascendancy because of such observations as the geographic limitation of pellagra to only a few of the areas of the world in which corn was the main staple; the appearance on the island of Corfu of pellagra after the locals stopped growing their own corn and began importing corn from Romania; the isolation of numerous organisms and especially molds from corn; and the claims of a famous Italian physician, Cesare Lombroso, that he had caused pellagra in animals and humans by injecting an alcoholic extract of damaged corn.
In 1911, Casimir Funk, a Polish-born chemist working in London, isolated a substance from rice polishings that cured polyneuritis in children. In 1912, Funk proposed the term “vitamine” for unidentified substances need to prevent certain nutritional diseases. He specifically named pellagra, along with scurvy and beri-beri, being likely caused by a specific vitamin deficiency. In October 1912, Fleming Mant Sandwith (1853-1918) of London presented a paper at the second National Pellagra Conference in Columbia, South Carolina, in which he asked whether pellagra might be an outward manifestation of a deficiency of a specific substance. In 1913, Sandwith published his views in a paper entitled “Is Pellagra a Disease Due to Deficiency of Nutrition?” However, at least two groups of investigators had already claimed to have dispelled faulty diet as the cause of pellagra, and moreover, many people had become preoccupied with the idea pellagra was caused by an infectious agent, perhaps transmitted by insects. Thus, the stage was set for Goldberger to prove them wrong.
