“fighting an unseen enemy”: the infectious paradigm in the conquest of pellagra

P1: GYQ

Journal of Medical Humanities [jmh] ph130-jomh-375319 June 19, 2002 7:50 Style file version June 4th, 2002

Journal of Medical Humanities, Vol. 23, Nos. 3/4, Winter 2002 (C© 2002)

“Fighting an Unseen Enemy”: The InfectiousParadigm in the Conquest of Pellagra

Chris Leslie1,2

This essay is concerned with popular and biomedical accounts of the appearance ofpellagra at the turn of the last century. Many of these accounts portrayed the diseaseas communicable despite early evidence to the contrary, which suggested it wasattributable to nutritional factors. The nonspecific nature of its symptom profile,along with the enormous range of cure-alls offered to the public, made the etiologyof pellagra open to a variety of interpretations. However, as the author shows, theinfection paradigm and genetic determinism hindered efforts to understand andtreat pellagra.

KEY WORDS: pellagra; social attitudes.

The scourge of pellagra seemed to appear suddenly in the United States inthe early 1900s and was immediately declared to be an emergency. Newspapersand popular magazines ran stories counting the deaths and predicting more unlessthe epidemic could be checked. State legislatures held conferences and appointedtask forces to determine how to contain the disease. But in truth, there was noway to “catch” pellagra except from eating poorly, and what was thought to be aninfectious disease imported from Europe turned out to be the result of malnutrition.Nonetheless, medicine provided “cures” that were quite deadly in themselves, andincreased efforts to defeat an infection that was not there took their toll on patients.

What was called pellagra is known today to be caused by a deficiency ofniacin. People whose diets contain sufficient meat, eggs, and milk consume enoughniacin or synthesize it from other protein. The poor, the institutionalized, and thosewho cannot control their own diet often do not have a varied enough diet and candevelop pellagra, a disease known for its triad of symptoms—dermatitis, diarrhea,

1American Studies, CUNY Graduate Center, New York, NY.2Address correspondence to Chris Leslie, 323 Schermerhorn Street #4, Brooklyn, NY 11217; e-mail:[email protected].

187

1041-3545/02/1200-0187/0C© 2002 Human Sciences Press, Inc.

P1: GYQ


188 Leslie

and dementia—which can conclude in death. Barrett-Conner (1967) notes thatniacin deficiency manifests itself first in tissues with high energy requirements(such as the brain) and tissues with high turnover (such as skin and mucosa). Niacindeficiency causes characteristic skin lesions that look like a symmetrical sunburnon exposed areas of flesh, as well as the paranoia and other mental manifestationsof pellagra. Spivak and Jackson (1977) found that the first symptoms occur withintwo months of deficiency, and that the symptoms are not the same in every patient.

While pellagra has almost been eradicated in the United States, sporadic casesdo occur. There is no simple confirmatory test for niacin deficiency, with diagnosisbased on the response of the skin lesions to niacin and adequate diet (Spivak &Jackson, 1977). Today in the United States, pellagra mostly occurs in alcoholicswho have substituted alcohol products for much of their diet, or as a result ofthe blockage of the synthesis of niacin by certain pharmaceuticals (Stratigos &Katsambas, 1977). Pellagra also occurs in any area struck by famine.

The faith in an infectious paradigm caused knowledge about pellagra’s dietarybasis to be ignored and resulted in deadly treatments. Pellagra had all the indicatorsof an epidemic disease, especially its increasing case rate, which seemed to indicatethat it threatened to escape the confines of the southern poor to attack the largerUnited States. That malnutrition was mistaken for an infectious epidemic in theUnited States at this time was not, however, a coincidence. The turn of the centurywas an era in which infectious disease fell to the power of bacteriologists whoproved anthrax, tuberculosis, diphtheria, typhoid, tetanus, bubonic plague, andsyphilis to be caused by microorganisms. As a further complication, most treatmentprograms had in common the offer of rest, freedom from irritants, and wholesomefood. The fact that pellagra was easily cured by a better diet allowed all kinds oftreatments to be promoted because, while in the physician’s care, patients weregiven the balanced diet that alone would have restored them to health. The supposedsusceptibility of immigrants and the poor, and their improvement while in the careof medical professionals, served to create communities of sufferers, a conceptthat led some professionals to search for genetic markers. Given pellagra’s basis inmalnutrition, it is disappointing that this search appeared successful. The infectiousparadigm and genetic determinism resulted in deadly treatments and delay of acure while established knowledge about the disease was ignored in favor of exotictheories of how it might be cured.

THE APPEARANCE OF PELLAGRA

The appearance of pellagra in Europe was concurrent with the use of cornas a staple crop in the 1700s. (Europeans called corn “maize”; “corn” was a wordused to describe any grain prior to the introduction of corn from the New World.)While corn is high in niacin, the niacin is in a bound form that is released onlyif subjected to an alkaline solution, such as the lime used by Latin American

P1: GYQ


The Infectious Paradigm in the Conquest of Pellagra 189

peoples in the production of tortillas. Pellagra is also rare in areas where rice isconsumed, because rice is high in tryptophan, which is used to synthesize niacin(Des Groseilliers & Shiffman, 1976). Corn became popular in the eighteenth andnineteenth centuries because it provided many calories cheaply. The concurrentappearance of pellagra was attributed to an exclusive corn diet or, more frequently,to eating spoiled corn or corn products. Since pellagra was found to occur in thespring in populations that used a great deal of corn, it was thought that improperlystored corn was to blame. Today we understand that a long winter of eating onlystored corn and corn products resulted in a niacin deficiency that disappeared onceother foods became available.

A few cases of pellagra were recorded in the United States after the CivilWar, but mostly there was no mention of it until 1907 when G. H. Searcy reportedthere had been cases for many years in a state hospital at Mt. Vernon, Alabama.In 1908 two doctors from Columbia, South Carolina traveled to Italy to studythe disease and on their return announced they were able to determine cases withaccuracy. Their definite diagnosis led to the discovery of many new cases, as theythemselves made the diagnoses, as well as training other doctors to do so. Thespread of knowledge prompted others to remember cases that perhaps had goneundiagnosed. Health officials were concerned enough to establish conferences andbegin investigations. Pellagra practitioner George M. Niles (1916) noted: “Theseconferences reached the ear of the American people and established it as a problemto even the most skeptical” (p. 30).

Many different entities, civic and private, studied the pellagra problem, andthere were as many estimates as to the scope of the disease. The Tristate MedicalSociety (Mississippi, Arkansas, and Tennessee) estimated that there would be one-half million cases of pellagra in 1912. In Spartanburg, South Carolina, pellagratook first place for the cause of death in 1913, with 600 cases in the county. ThePeoria Hospital for the Insane, located in the principal seat of pellagra in Illinois,reported not only a high incidence of cases but also a high mortality rate. At itsheight, pellagra was blamed for 10,000 deaths a year in the South, and 200,000were crippled each year by the disease.

The public’s fear of pellagra was inflamed by newspaper reports of the rapidlyspreading disease, which suggested that eighty percent of those infected would die.Pellagra manifests itself physically by a reddening of the skin like sunburn, whichprogresses to symmetric scaly eruptions on both sides of the body. Stomach upset,diarrhea, and dizziness are followed in some cases by severe mental symptoms(dementia). “Some had destructive tendencies; they might pull out their eyebrowsor try to set their houses on fire. Others feared for their safety, imagining thatthe neighbors planned to assassinate them” (Etheridge, 1972, p. 8). Some caseswere fatal, and those who survived were observed to have regular outbreaks of thedisease each spring and often perished after years of repeated incidents.

Joseph Goldberger of the fledgling Public Health Service was able to sup-port his suspicion that pellagra was not contagious with experimental data, but

P1: GYQ


190 Leslie

his results were ignored for many years. His ability to administer a cure in 1915,first in the form of a diet higher in protein (then via brewer’s yeast) was unable toprevent a death toll that reached its height in 1928. Goldberger’s work was not new,however. Roe (1980) reports that pellagra’s first modern observer, Gaspar Casal,knew in 1735 the dietary cure for pellagra. By providing milk, cheese, and otherprotein-rich foods to the afflicted, Casal was able to satisfy niacin deficiency and“cure” pellagra in Spain. Between Casal’s observations and Goldberger’s, how-ever, came a period seeped in the power of bacteriology. Practitioners believedpellagra was a disease one “caught” from one’s family, neighbors, or ancestors,and so gave scientific credence to undesirability. It allowed civic forces to alignwith the medical establishment to methodize the loathing of undesirable citizensthat they called “pellagrins” and explain their supposed weaknesses and laziness.More than being the triumph of science, pellagra is a horrifying case-study in themechanics of ideology.

THE BIRTH OF THE INFECTIOUS PARADIGM

Pellagra had been known for many years in Europe (Italy, in particular),but it was not until the turn of the century that it was discovered in the UnitedStates. Even though pellagra was not infectious, it came at a time when medicine’semphasis had turned from prevention to cure. Recent success in defeating infec-tious disease meant pellagra would be treated as an infectious disease. Until theturn of the century, most scientists believed that filth was the cause of sickness.This belief created the obvious program to prevent disease: providing clean livingconditions.

Health in the United States had been the province of local authorities until1872, when the federal government made its first excursion into disease prevention.Increased knowledge of the mechanics of infection led to a group of experts whosought to educate the public and policy makers about the true causes of sickness.One of these experts in municipal health was Charles Value Chapin. In his bookSources and Modes of Infection(1910), Chapin fought the perception that themajority of infectious diseases originated in filth and was particularly concernedwith infectious agents such as the rat flea, which could carry disease to humans.Chapin argued that unrecognized, mild cases of disease were more common thanthe recognized, severe cases, and predicted efforts to stamp out contagious diseaseby isolating visible carriers would fail because their methods did not treat theunrecognized cases.

As the century progressed, medicine divided the general idea of “illness” intoseparate responsible agencies and developed specific causes and effects for eachailment. Vogel and Rosenberg (1979) describe how the development of distincttreatments for different ailments increased during this period. There were fewdiscoveries until medicine approached the new century: in 1890, the introduction

P1: GYQ



of an antitoxin for diphtheria; in 1894, the introduction of an antitoxin for tetanus;in 1907, the introduction of salvarsan to treat syphilis (pp. 446–48).

Likewise, scientific tests and measures began to replace the outdated filthmodel of disease. When advances in medical science provided a test for infection,antiplague campaigns were developed that captured rats, tested them for plague,and eliminated packs that had the disease. Health experts were wildly successfulin identifying and eliminating outbreaks and their bravado was wildly apparent:Surgeon General Rupert Blue, at the completion of a 1908 plague control campaign,was honored at an outdoor luncheon whose slogan was “San Francisco is so cleana meal can be eaten in the streets” (Williams, 1951, pp. 132–133).

The success of the infectious paradigm informed thinking about pellagra.One of the more prevalent theories to account for the spread of pellagra wasmade by Louis W. Sambon, a lecturer at the London School of Tropical Medicine.Sambon began a prolonged investigation into pellagra in 1900 and in 1905 con-cluded that protozoa similar to the malarial parasite, transmitted by the simuliumfly or so-called sand fly, caused the disease. He found no such parasite, but he sus-pected the existence of one because of the similarity of pellagra’s behavior withother parasitic diseases.Naturepublished his findings and elucidated his theoryin 1910, which was based on an analogy to another unproved theory, the agent oftransmission of yellow fever. While no parasite had been found in the mosquito,“the experiments carried out are so conclusive.. . .Pellagra is in the same category”(“Recent investigations,” p. 539). WhileNature used the word “experiments,”Sambon did not base his conclusion on any experimental evidence. According tothe article, Sambon’s proof was based simply on reasoning. Sambon observed thatthe centers of the disease remained constant and were in rural areas near bodies ofwater. He concluded that there must be an insect to blame, particularly since theyearly appearance of the adult sand fly coincided with the seasonal recurrence ofpellagra.

In his paper, Sambon readily admitted that he simply drew attention to the“many analogies” between pellagra and other protozoal disease (Sambon, 1905).In order to discard the deficiency theory, he used broad, unproven strokes. Withoutany quantitative results, he said that many populations subsisted on rice or potatoes,and these populations were free of pellagra. He suggested that corn was much morenutritious than rice or potatoes and proclaimed that malnutrition would “never”bring about the symptoms of pellagra. Sambon made three excursions to test hisideas, the first financed by private donations and the others by Henry S. Wellcome, awell-known health entrepreneur. Sambon did not conduct experiments during theseexcursions; instead he recorded observations that confirmed his hypothesis andcontinued to use deductive reasoning to blame an unknown insect-borne parasite.For instance, on visiting an asylum in Barbados, Sambon noticed new cases ofpellagra in ten inmates who had stayed more than four years in the asylum, anddeduced that their pellagra must have originated within the institution by meansof an infectious agent (Sambon, 1917).

P1: GYQ


192 Leslie

While all aspects of Sambon’s findings were not accepted in the UnitedStates, his conclusions contributed to a rising fear of pellagra and are indicativeof the faulty reasoning based on suspect investigations in the history of pellagrain the United States. By making reference to Sambon as “the European expert onpellagra,” American doctors were able to suggest a scientific foundation for thecommunication of pellagra, even though they, like he, lacked any evidence. Theidea that pellagra was communicable fit within preexisting ideas of disease andthe undesirability of its victims, and the infectious paradigm was readily accepted.

AN IMPERFECT MODEL DRIVES MISTAKEN SOLUTIONS

Thus, concurrent with the “discovery” of pellagra in the United States, therewas a new faith in science’s ability to label each human ailment and provide acure with a specific medicine. This led to deadly results in pellagra, which hadno infection to “cure.” There was no accepted truth about pellagra and doctorsbelieved that they could study the advance of this new disease in a populationand experiment to find cures. Edward Wood (1912) wrote that the appearance ofpellagra was “one of the most interesting chapters in American medical history,”and that the profession should be excited, as it was rare to witness the beginnings“of an entirely unknown disease on virgin soil” (p. vii) and to watch how scienceadapted itself into a new field.

Wood worked for years to discover some type of blood reaction that woulddefinitely indicate pellagra. Many doctors were convinced that there was a classof patients—particularly those who were sluggish or indolent—that suffered frompellagra but did not show the characteristic rash. These cases echoed Chapin’s fearof hidden carriers. Wood believed that a blood test would help uncover pellagrawithout the skin lesions: “There is no place in medicine in which a blood reactionof some sort would be of so great value” (p. 287). Unfortunately for Wood, all hefound was an increase in lymphocytes, which he knew to be common in all typesof intestinal infections. As for treatment, Wood believed that the parasitic origin ofthe disease recommended arsenic. While he had no evidence of parasitic infection,his belief was reinforced by the success of arsenic treatment. While being treated,he recommended a milk diet, bed rest, and the elimination of corn from the diet.In severe cases, Wood attempted blood transfusions and salt baths.

Several practitioners proposed blood transfusions. Believing that vegetablepoisons in decomposing grain caused pellagra, Herbert P. Cole pointed to the beliefthat a serum made from the blood of a recovered sufferer of pellagra could havea curative effect, and surmised that a blood transfusion from a recovered casewould have a similar effect (Cole, 1909; Cole & Winthrop, 1909). The theorywas “proved” because the patient recovered, but it is not hard to see why: After atransfusion, the patient was removed from all medication (ostensibly to isolate thevalue of the transfusion) and given hospital care, which is of course what cured

P1: GYQ



the deficiency. In a related case, Palmer and Secor (1915) reported the successof their treatment by autoserotherapy: The doctors used a hypodermic needle todraw serum from a blister they raised on the chest of a patient and then reinjectedit. They surmised that as the antigens in the serum were reabsorbed, the patientproduced antibodies. While they were not sure of the exact process, they were suretheir patients were recovering while under their care.

Other doctors were heartened as pellagra seemed to submit to their theories:C. C. Bass (1911) noted that exposure to X-rays and sunlight caused severe burnsin pellagrous patients that would not harm a normal patient. Today we know thattissues with high turnover in a person suffering from niacin deficiency are not ableto recover from radiation like those of a healthy patient, but Bass saw this as anindication of the need for the isolation of patients in rooms lighted with ruby lightsand with ruby glass in the windows. His observation that pellagra occurred in thebeginning of the warm season led him to transport patients to colder climates andwas so heartened by their response that he proposed creating refrigerated wards forpatients, never suspecting that the better food his patients received while in his carewas the true reason for their recovery. Even doctors who did not hold to the tradi-tional line of blaming corn saw success: Roy Blosser (1915) believed that pellagrafollowed in the wake of modern methods of sugar manufacture, and blamed thenoncrystallized solids of sugar (yellow sugar, brown sugar, and syrup). He saw suc-cess in strict dietary management where sugar (except a small amount of granulatedsugar on breakfast cereal) and all sweets, including soft drinks, were forbidden.

GOLDBERGER’S BREAK FROM ACCEPTED PRINCIPLES

The establishment of the Marine Hospital Service (to be known after 1912as the United States Public Health Service) centralized the control of hospitals atthe points of entry to the United States as well as provided a mobile medical corpsavailable for service in any area (Williams, 1951). To implement the changes inhealth policy, a corps of medical officers was trained and organized to investigateoutbreaks as they occurred. One of these experts was Joseph Goldberger, the sur-geon of the PHS, whose work on pellagra is still considered a masterpiece of theepidemiological method. The types of experiments he conducted were not revo-lutionary; previous researchers had tried many of them. Goldberger’s success wasin his systematic and scientific method, which gave him the credibility that otherslacked. Goldberger was part of a larger medical corps ready to be dispatched bythe federal government wherever a problem was identified; his experience had ledhim to deflate fears of a “new disease” that was, in fact, an insect infestation andto improve laboratory methods to prevent the spread of infectious disease.

By the time Goldberger entered the arena, the idea that pellagra was com-municable had taken firm hold of public policy makers. Alarmed by a disturbingnumber of cases at the Illinois State Insane Asylum, the governor appointed an

P1: GYQ


194 Leslie

investigative committee that found nearly 500 cases in the state, mostly in in-sane asylums. The Illinois Pellagra Commission wrongly concluded in 1911 thatpellagra was due to a microorganism in the intestinal tract introduced by ingestingcorn. The deficiency of animal protein in the diet was mentioned as a secondaryor predisposing cause, but this undiscovered, hidden microbe was the primaryagent. The commission noted with pride that their investigation had overthrownthe fallacies of the past.

The Thompson-McFadden Commission was formed in 1912 to find the causeof pellagra. The private contribution of Colonel Robert M. Thompson and JohnH. McFadden was used to support a group of federal and private doctors from abase at the New York Post-Graduate Medical School (“Keep on,” 1913). Their firstreport in 1913 concluded that pellagra was a infectious disease with an unknownmeans of communication. Again, the belief in infection was not due to the discoveryof an infectious agent, but rather the suspicion that pellagra acted like an infectiousdisease. The commission found that new cases occurred near existing cases eightypercent of the time, and nearly always seemed to occur where another personwith pellagra already lived. Such investigations were bound to conclude that aninfectious agent was to blame.

Public policy makers desired definite data to derive conclusive answers, andfaced with evidence that not all eaters of corn were taken by pellagra, they conjuredan unseen, unknown agent to carry the blame. At the same time, this study andothers demonstrated that communities which public policy makers considered to be“undesirable” would be stricken. The public’s impression of the disease definitelyleaned to the side of the infectious agent. TheLiterary Digestreported in 1913that there was ample evidence to discard the dietary factor. The writers announcedthat the ancient Italian doctors were mistaken about the basis of pellagra in spoiledcorn and they were sure that pellagra was an infectious disease imported from Italyalong with the “hordes of immigrants who have arrived in the last 30 or 40 years.”The School of Tropical Medicine’s Sambon was proclaimed to be the best hope forconquering the disease in his search for an insect that carried the disease. While thesimulium fly was a likely cause, the authors said, the proof could be devastating:“What makes the matter worse is the discovery that the insect is very widespread”(“Another fly,” p. 1003).

Goldberger’s superior cast him into this state of affairs in February 1914.While there was much suspicion about pellagra, its origin and cure, there was noone accepted theory or method of treatment. Goldberger reviewed the literatureand surveyed patients in hospitals and asylums in Spartanburg, South Carolina;Milledgeville, Georgia; and Jackson, Mississippi. In each institution he found onesurprising phenomenon: not one staff member had the disease. It was this lackof transmission of this supposedly contagious disease that Goldberger found mostbaffling. In studying differences between the afflicted and not afflicted, he found themost obvious difference to be dietary: those with the disease lived in circumstancesbeyond their control and were often fed substandard food. Goldberger discarded

P1: GYQ



any theory that accounted for the transmission of pellagra because there was notransmission from the patients to doctors or nurses. In the summer of 1914 hepublished a paper that denied pellagra was infectious.

The idea that pellagra was caused by a faulty diet was not new; it was suggestedby the Italian doctors’ old-time cure of fresh milk and meat. The incidence ofpellagra was primarily rural and its association with poverty led Goldberger toblame diet. Writing of his initial survey of hospitals and institutions, Goldbergernoted the staffs spent much of the day in close proximity to the inmates andwondered why, if pellagra was communicable, should there be an exemption ofnurses and attendants? (Terris, 1964, p. 19). He found that variations in diet as arule could be used to determine who would develop pellagra. Nurses, for instance,often took the right to select the best food and made sure to have a sufficientquantity before serving the patients. They also had the opportunity to supplementtheir diets with food from the outside. Patients, however, were at the mercy of whatwas given to them.

The idea that pellagra was communicable was so widespread at the timeGoldberger began to work that he had to go to great lengths to show that despiteplenty of opportunity it was not infectious. He first attempted to cause the transmis-sion of pellagra by injecting healthy subjects with “every kind” of tissue, secretion,and excretion from “grave and fatal cases” (Terris, 1964, p. 24). He started withinjections in rhesus monkeys that failed to produce results. Later, what his wife(1956) called “the most nauseating diabolical concoctions” of blood, feces, andurine from the sufferers of pellagra were injected into and swallowed by him-self, his wife and his staff; still, he could not produce pellagra. He then increasedthe amount of fresh milk, meat, and eggs in the diets of pellagrous inmates andfound pellagra immediately eliminated. With the help of Mississippi’s governor,he gained the pardon of volunteer convicts at the Rankin State Prison Farm in ex-change for participation in a 1915 experiment that produced pellagra symptoms bywithholding certain foods, which proved that the current state of medical knowl-edge regarding pellagra was based on suspicion and fear. Goldberger found noway to transmit the disease, and also found how it could be induced and “cured”by withholding or supplying essential vitamins.

While Goldberger was not able to explain the specific cause of pellagra, in1915 he announced that he was able to prevent it, cure the afflicted, and explainwhy other quack theories seemed to disperse it. He had established without a doubtthat the source of pellagra was not infection but improper diet, and that the curewas in better feeding. As Sydenstricker (1958) observed, while other methodshad surfaced that claimed to cure pellagra, Goldberger’s work proved that theseother methods succeeded because while in the care of the physician patients hadaccess to food that supplied the nutrients missing from their normal diet (p. 410).While the deficiency caused readily identifiable markers that indicated a need formedical care, these markers in no way justified the extreme measures taken. Onlythe previously formed beliefs about the deadly and contagious nature of pellagra,

P1: GYQ


196 Leslie

its origin in the undesirable immigrants and its prevalence among undesirablesoutherners, and the faith in science to deliver the population from disease could beused to ignore these facts and instead prescribe bizarre and often deadly treatments.

PRACTITIONERS CREATE COMMUNITIES OF SUFFERERS

Even after Goldberger’s work practitioners dealt with pellagra as an infectionand not as a niacin deficiency. In 1902, Henry Harris, a health officer in Georgia, wasone of the first to report a case of pellagra in the United States, typifying the stancetaken by those who subscribed to the infectious paradigm. After seventeen years ofstudy and practice, he reported his learning in a book,Pellagra(1919). His catalogof early symptoms included vertigo, depression, loss of appetite, indefinite pains,and constipation. (One can imagine a pauper or inmate with constipation wronglydiagnosed as having pellagra and subjected to a treatment regimen.) Harris blamedpellagra on spoiled corn; specifically, he suspected that a protean parasite infestedbad corn. While he had no specific evidence, Harris’s belief in this parasite causedhim to lump together disparate diseases under the rubric of pellagra. Pellagra,he wrote, “appears to manifest itself” in “the guise of certain maladies” that werethought to be distinct: “Among these may be mentioned acidosis, chronic gastroen-teritis, essential anemia, Addison’s disease, chronic degeneration with consequentatrophy of various organs, thyroid disease, amyotrophic lateral sclerosis, tetany,paralysis agitans, pseudo-meningitis, psychoses, typhoid pellagra, and pellagrasine pellagra” (p. 301).

The last of the list, pellagra sin pellagra, was a term invented to describe theappearance of the mental symptoms of pellagra without a manifestation of thecharacteristic symmetric rash. It betrays Harris’s effort to recast many differentdiseases in the single mold of pellagra. Pellagra sine pellagra is indicative ofthe entire list in that it can be made to include anything of which a patient mightcomplain. Thus, a practitioner could use the suspicion of pellagra to group togetherpatients who he deemed to be undesirable. Harris’s grocery-list of maladies coveredanything a practitioner might observe in his patients that demonstrated deviationfrom accepted norms.

To make matters worse, Harris believed that the “pellagrous intoxication”proceeded between generations, causing descendants of the victims to “presentdistressing malformations and deformities” (p. 301). This observation, not uniqueto Harris, illustrates pellagra’s use as a means to create a community of undesir-ables. While medicine tried to explain disease by microbes, sociology was tryingto explain poverty by genetic traits. Sociologist Charles Loring Brace (1880) usedpersonal experience as evidence for his theory that inherited “gemmules” con-tained the latent tendencies of one’s ancestors that work in the blood to createan irresistible impetus to crime and pauperism. Brace concluded that the mostpowerful source of crime is the inherited tendencies that adult criminals passed

P1: GYQ



to their offspring; paupers resulted from their ancestors’ abnormal and excessiveindulgence of “certain appetites or habits” (p. 43).

Charles Davenport (1910), a founder of the American eugenics movement,used a simplistic understanding of genetic inheritance to reduce the individual toa mosaic of characteristics transmitted from blood relatives. While he providedno record of research to support his theories, he asked the reader to accept thatsuch nebulous qualities as taste and temperament were inherited like hair color.He concluded that poverty was genetically inherited and held out the hope thatthe “fearful drag on our civilization” from the genetically challenged could beaverted by legislation that would segregate or sterilize “idiots, low imbeciles,[and] incurable, dangerous criminals” (pp. 31–34). In a paper published in 1916promoting a hereditary paradigm of pellagra, Davenport provided a vivid exampleof how the infectious paradigm was easily adapted to the ideology of creating aclass of undesirables. Davenport, it seems, found a “hereditary factor” that forty tofifty percent of children whose parents had pellagra contracted the disease; it was,of course, the similarity of diet in a family that caused the seeming transmissionbetween generations. He also used genetics to explain the characteristically proteannature of pellagra. On reviewing family histories of the afflicted, he found somethat demonstrated no mental symptoms; in others, marked intestinal symptoms;in yet others, skin troubles. He sympathized with doctors who found making adiagnosis difficult, since the disease manifested itself in many different ways, andsurmised that certain biotypes reacted differently to the disease.

In fewer than twenty years of observations and case records, neither Harrisnor Davenport could have directly observed pellagra pass between more than twogenerations of sufferers. What, then, would lead them to the conclusion of a here-ditary transmission of this disease? These scientists turned hypothetical state-ments into medical fact. Certainly there was not time to establish conclusively thatpellagra passed between generations. Their conclusions, then, stemmed from theirobservation that undesirables often were associated with each other and tended tohave undesirable offspring. From this hypothesis they, like Brace, created a mis-taken theory they claimed to be scientifically based, and their misguided belief inan infectious agent condemned an entire class of people to fear and harsh medicaltreatment.

Harris even went so far as to say that the offspring of people with pellagrashould not be insurable on the same actuarial tables as “persons of better ancestry”(p. 366), believing that pellagra was a catastrophe that threatened the strengthof the nation. He certainly had a vested interest in creating this notion, that is,in maintaining his private practice, securing public addresses, and selling bookson pellagra. But his belief also related to his notions of the population. Certainsegments were thought to be of lesser-quality stock than better-bred segments, notsimply in morals and education but also in their physical quality as organisms. ToHarris, the pellagric condition, while unfortunate, simply demonstrated that certain

P1: GYQ


198 Leslie

individuals were of lesser quality than others. These lesser-quality organisms werethought to be, through the very fact of their genetic inheritance, poor examples ofthe species, and scientific language was used to justify this rationale.

FALLACIES LINGER AFTER THE CURE

For many years after Goldberger’s proof that diet could cause and cure pella-gra, other cures were hypothesized and administered while Goldberger’s work wasdismissed. The Thompson-McFadden Commission announced in November 1916that pellagra was infectious and spread by ineffective sewage disposal. The con-clusion of the commission was based on its three years’ work in Spartan Millswhere a new sewerage system was built; old cases were found to persist but therewas only one new case, which was in close proximity to an existing case. Whilethe American public “clung tenaciously” to the idea that pellagra was dietary inorigin, the commission urged that there be more attention paid to the fact thatthere were cases among the well-to-do and that most new cases occurred in theimmediate vicinity of pellagra suffers (“Pellagra is found,” 1916).

D. H. Yates dismissed Goldberger’s theory of a “one-sided diet” with thevacuous arguments that nutritious foods were abundant in the South and therewas no reason to suspect eating habits. Yates believed he cured pellagra with staticelectricity, which he administered to forty patients a year for seven years. In articlesin 1915 and 1921, Yates described the machine he used to administer an electriccurrent to his patients to cure pellagra. He admitted that he did not know why, orhow, the method succeeded, but he believed a current traveling from head to footinduced a vibration in every cell of the body that eliminated the disturbance causedby the disease. His patients were seated barefoot on an insulated platform, theirfeet resting on a metal plate connected to the positive side of a static generator.The negative side was connected to a crown and placed on the patient’s head. Themachine was engaged and the power increased to a level just shy of causing themuscles to contract and continued for thirty minutes, twice daily. Yates did notquite know what it was, or what it did, but felt it certainly would provide a benefitbecause it was a force of nature at the direction of science.

Yates prescribed twelve to twenty weeks of treatment, with symptoms ex-pected to improve in the first week, plus four weeks’ treatment each spring forthree years after cure to prevent a relapse. Before discarding his work, however, itmust be mentioned that he reported remarkable success: Of one hundred patientstreated, ninety-four were cured. The static treatment itself perhaps was uselessexcept for inducing a soothing effect, but his patients received good hospital care,including healthy food and rest. They were also removed from their environment,which for many of Yates’s patients included the prevalence of narcotics. This carewas the very secret of Yates’s success.

Yates’s patients were fortunate. His success rate was high, and his treatmentbenign. The belief that an infectious agent caused pellagra led to attempts to destroy

P1: GYQ



that agent with poison, a popular practice at the time. To some doctors, pellagrarepresented the encroaching decay of the human position in the universe and neededto be dealt with harshly. G. M. Niles (1916) treated both the symptoms and the sup-posed cause of pellagra harshly. Diarrhea was addressed by bismuth-betanaphtoland resourcin in milk of bismuth, powdered opium, or tannigen. Indigestion wassupposed to be caused by a lack of acid in the patient’s gastric solutions, indicat-ing ten to twelve drops of dilute hydrochloric acid thirty minutes after meals tolessen “that heavy feeling.” For anorexia, tincture of nux vomica, condurango, orcalumbor quassior; for constipation, castor oil or enemas.

As for the treatment of pellagra itself, Niles recommended an alternationof iron arsenate and sodium cacodylate daily for two to three weeks, then everysecond day for two to three weeks, and then once a week. Sometimes the arsenicwas administered in the form of Fowler’s solution, or potassium arsenate. Sincethere was no set amount to be taken, doctors determined the patient’s tolerance andadministered the medicine at a level just beyond it. Treatment started at five dropsand increased by one drop until the patient’s limit was reached. Indicated bypuffiness under the eyes, the patient’s limit was the amount of poison he couldwithstand before death. After a rest of two days, the treatment was repeated.

Niles’s medicinal treatment was accompanied by less caustic, but still intru-sive, care. Hot or cold baths, salt baths, douching, moist or dry rubs, and specialrubs were used with the intent to increase oxidation of the tissue, encourage elim-ination, sharpen the appetite, and improve digestion. Vaginal or rectal douchinghad “a useful place,” as did the consumption of a sufficient amount of water. Thesetreatments accompanied by enforced rest in an environment with good ventila-tion, restricted light, freedom from disturbing noises, cheerful companionship,and clean food made for a successful cure without chance of a deadly recurrence.Pellagra, Niles believed, was a chronic disease that would lurk in the patient foryears and spring forth with a fatal impetus after an unspecified latent period. Neverfatal on the first appearance, on recrudescence the pellagric toxins gained sufficientmomentum to cause damage or death. For this reason, Niles believed in a swift andforceful treatment to prevent the disease from gaining a stronghold: “The simplestmanifestation [of pellagra] is a proof that there lurks in the system a subtle, amysterious, an intangible toxin, one whose lair has not as yet been located.. . .Weare, therefore, in a sense, fighting an unseen enemy, and until this enemy is forcedinto the open, we must necessarily rest in an uncertainty” (p. 179).

In 1921, after pellagra had been under control for many years, convulsions inthe cotton market led to widespread famine and the incidence of pellagra surged—and still there was doubt as to the cause. ANew York Timeseditorial on July27, 1921 (“Pellagra in the South”) weighed evidence that pellagra was dietaryor infectious and concluded, “whatever the real cause. . .preventative measuresmust be taken.” In August of the same year, Edward M. Perdue wrote a letter totheNew York Timesto claim that the current thinking about pellagra was wrong,insisting that drinking soft water that came from a clay soil caused pellagra and

P1: GYQ


200 Leslie

was cured by the hypodermic administration of sodium citrate. This finding, whichhe said was “based upon the very best scientific findings,” was the conclusion ofa book he helped to translate in 1916.

Once the infectious paradigm was no longer advanced, there was still theproblem of how to stop pellagra from occurring. The late 1920s saw a frighteningincrease in the number of cases. In response, state boards of health dispatchedmobile educators such as Hilla Sheriff to help the people of the mill towns whohad heard they could stop pellagra but did not know how. In 1931 Sheriff’s health-mobile, a trailer pulled by a car, traveled to communities with an exam room fortreatment and an area to demonstrate how to can fruits and vegetables for year-round consumption (Hill, 1995). Nicotinic acid, the specific nutrient missing inthe diet of those who suffered from pellagra, would not be available until the endof the decade. Sheriff’s work took advantage of the existing, albeit incomplete,knowledge of pellagra and proved crucial even after nicotinic acid was available.Since only a physician could administer nicotinic acid, social workers like Sheriffpromoted the lifestyle changes needed to erase pellagra.

Today, a final fallacy lingers. Occasionally one will read echoes of an ideapromulgated by early nutritionists that the sudden appearance of pellagra in theAmerican South at the turn of the century was due to a new process of milling corn.Many of the malnourished inhabitants of the mill towns ate corn grown in the West,which was milled and shipped by railroad, as a cheap source of calories. In orderfor the corn meal to have a longer shelf life, the corn was degerminated and thus,it is thought, lost much of its nutrient value. While the degermination of corn wascontemporaneous with pellagra, it does not explain why European communitiessuffered from pellagra before the advent of the degermination process; in thenineteenth century, corn was stone-ground. Nor does it explain why pellagra failedto beset Latin American populations that subsisted largely on corn: They used limeto release the niacin.

CONCLUSION

The story of pellagra has more to offer than a drama of science’s triumph overthe unknown. Those who advanced the infectious paradigm held so much powerat the time that they were able to impose their beliefs over existing knowledge,leading to public fear and deadly treatments aimed at curing an absent infection.The story of pellagra also demonstrates that what are commonly thought to be“breakthroughs” in science often are not universally accepted. Goldberger pub-lished modern scientific evidence that pellagra could be caused and cured by dietin 1915, even though he did not know the exact deficiency he cured. And yet thevery next year an association of public and private doctors announced that, whilethey did not know how, pellagra must be contagious. For many years after the

P1: GYQ



cure, theories were advanced in direct contradiction to Goldberger’s findings thatsuggested pellagra was infectious or came from environmental factors.

This paper has demonstrated the damage done by the infectious paradigm atthe turn of the century, but not all historians feel the paradigm was culpable. Kunitz(1988) has advanced the proposition that the infectious paradigm did not delay, butinstead laid the groundwork for, the defeat of pellagra. The germ theory of disease,he argues, caused scientists to redefine their notion of disease and allowed doctorsto move beyond the control of symptoms. According to Kunitz, when germ theoriesfailed to explain pellagra, doctors were forced to evaluate the dietary theories andthus the infectious paradigm was an important motivating factor. Doctors wantedto know the cause of pellagra, not just alleviate its symptoms, which led to theisolation of the nutritive element to prevent pellagra.

It is true that the increasing sophistication of epidemiology, and specificallythe creation of the Public Health Service’s medical corps, led to the defeat ofpellagra. However, Goldberger was able to cure pellagra in a year of study. Theexamples in this paper make it clear that the infectious paradigm overruled the ex-isting knowledge about pellagra for many years and misapplied treatments createdfear and suffering. The infectious paradigm satisfied the need of public officialsand practitioners to explain the undesirability of the malnourished.

The epidemic of pellagra is today often overlooked in the history of the UnitedStates, but it is an important moment in the development of science and medicine.Medical historians are all too proud to report the success in creating a “magicbullet” supplement to balance the diet. But practitioners disregarded evidence thatpellagra was caused by a poor diet in favor of fruitless searches for blood reac-tions and unseen pathogens, and used wild theories to promote deadly treatments.What is lacking is an awareness of the deaths, mistreatment, and suffering that canrise from mistaken beliefs. The failure of the medical establishment to understandpellagra should have been a rallying-call, creating an awareness of the danger ofholding mistaken models in the presence of conflicting information. The isola-tion of nutritive elements, along with the ability to administer them as a salablesubstance, is seen as a triumph of modern medicine and not as a failure. Pellagrastymied medical science, and the methods of diagnosis and treatment until theacceptance of the dietary cause make pellagra a revealing example of the dangerof the infectious paradigm.

REFERENCES

Another fly to swat. (1913, November 22).Literary Digest, 1003.Barrett-Connor, E. (1967). The etiology of pellagra and its significance for modern medicine.American

Journal of Medicine, 42,859–867.Bass, C. C. (1911). Treatment of pellagra.Southern Medical Journal, 4, 523–527.Blosser, R. (1915). Some observations further incriminating sugar-cane products as the main cause of

pellagra in the South.Southern Medical Journal, 8, 33–36.

P1: GYQ


202 Leslie

Brace, C. L. (1880).The dangerous classes of New York, and twenty years’ work among them.New York:Wynkoop & Hallenbeck; reprint, New Jersey: Patterson Smith, 1967.

Chapin, C. V. (1910).Sources and modes of infection.New York: J. Wiley Sons.Cole, H. P. (1909). The transfusion of blood as a therapeutic agent with report of transfusion in a case

of pellagra.Southern Medical Journal, 2, 631–638.Cole, H. P., & Winthrop, G. J. (1909). Transfusion in pellagra.Journal of the South Carolina Medical

Association, 5, 489–495.Davenport, C. B. (1910).Eugenics: The science of human improvement by better breeding.New York:

H. Holt.Davenport, C. B. (1916). The hereditary factor in pellagra.Archives of Internal Medicine, 18,4–31.Des Groseilliers, J. P., & Shiffman, N. J. (1976). Pellagra.Canadian Medical Association Journal, 115,

768–770.Etheridge, E. W. (1972).The butterfly caste: A social history of pellagra in the South.Westport, CT:

Greenwood Publishing.Goldberger, M. F. (1956). Joseph Goldberger: His wife’s recollections.Journal of the American Dietetic

Association, 32,724–727.Harris, H. F. (1919).Pellagra.New York: Macmillan.Hill, P. E. (1995) Go tell it on the mountain: Hilla Sheriff and public health in the South Carolina

Piedmont, 1929–1940.American Journal of Public Health, 85,578–584.Keep on pellagra work. (1913, March 31).The New York Times, p. 9.Kunitz, S. J. (1988). Hookworm and pellagra: Exemplary diseases in the New South.Journal of Health

and Social Behavior, 29,139–148.Niles, G. M. (1916).Pellagra: An American problem.Philadelphia: Saunders.Palmer, E. E., & Secor, W. L. (1915). The treatment of pellagra by autoserotherapy.Journal of the

American Medical Association, 64,1566–1567.Pellagra is found to be infectious—Thompson-McFadden Commission takes issue with Public Health

Service. (1916, November 19).The New York Times, p. 6.Pellagra in the South. (1921, July 27).The New York Times, p. 14.Perdue, E. M. (1921, August 18). Study of pellagra: Conclusions based on research by Italian scientists.

The New York Times, p. 10.Recent investigations on pellagra. (1910, October 27).Nature, 84,538–539.Roe, D. A. (1980). Attempts at the eradication of pellagra: A historical review.The Henry E. Sigerist

Supplements to the Bulletin of the History of Medicine, 4, 62–83.Sambon, L. W. (1905, November 15). Remarks on the geographical distribution and etiology of pellagra.

British Medical Journal, 2, 1272–1275.Sambon, L. W. (1917).Reports on pellagra in the West Indies, presented to both houses of Parliament

by command of His Majesty, November 1917.London: H. M. Stationery Office.Spivak, J. L., & Jackson, D. L. (1977). Pellagra: An analysis of 18 patients and a review of the literature.

Johns Hopkins Medical Journal, 140,295–309.Stratigos, J. D., & Katsambas, A. (1977). Pellagra: A still-existing disease.British Journal of Derma-

tology, 96,99–106.Sydenstricker, V. P. (1958). The history of pellagra: Its recognition as a disorder of nutrition and its

conquest.The American Journal of Clinical Nutrition, 6, 409–414.Terris, M. (Ed.). (1964).Goldberger on pellagra.Baton Rouge, LA: Louisiana State University Press.Vogel, M. J., & Rosenberg, C. E. (Eds.). (1979).The therapeutic revolution.Philadelphia: University

of Pennsylvania Press.Williams, R. C. (1951).The United States Public Health Service, 1798–1950.Washington, DC: Com-

missioned Officers Association of the U.S. PHS.Wood, E. J. (1912).A treatise on pellagra for the general practitioner.New York: D. Appleton.Yates, D. H. (1915). The treatment of pellagra by static electricity.Journal of Advanced Therapeutics,

33,60–73.Yates, D. H. (1922). Pellagra successfully treated by electricity.American Journal of Electrotherapeu-

tics and Radiology, 40,216–219.

“fighting an unseen enemy”: the infectious paradigm in the conquest of pellagra

Documents