Pellagra in the United States: A Historical Perspective

Kumaravel Rajakumar, MD, Department of Pediatrics, West Virginia University School of Medicine, Morgantown.

South Med J. 2000;93(3) 

In This Article

Epidemic in the South

In 1902, H. F. Harris, MD, an Atlanta physician, reported the first case of pellagra in the United States.[5] The patient was a poor Georgia farmer, who had always eaten a diet in which Indian corn was a staple and had had a recurrent, debilitating warm-weather sickness for nearly 15 years. Each spring, he became anorectic and lost weight. Typically, blisters erupted on his arms and legs, and he had extreme melancholia with suicidal ideation. The symptoms worsened during the summer and abated with the onset of cool weather. Despite adequate therapy of a coexisting hookworm infestation and treatment of pellagra with arsenic and iron, there was no sustained improvement. The patient was advised to move to a cooler climate and to avoid eating decomposed corn. In the years to follow, poverty and consumption of corn were the most frequently observed risk factors among pellagrins.

In 1906, George H. Searcy, MD, studied and reported an epidemic of pellagra among the hospitalized patients of Mount Vernon Hospital for the Colored Insane (Mount Vernon, Ala).[7] Of the 88 cases, 80 were female patients, the mean age was 34 years, and the case fatality rate was 64%. Most of the patients had been in good physical health before hospitalization. Two thirds had been in the hospital for more than a year. None of the nurses attending the patients were affected, despite handling the patients and sleeping in the halls near the wards. The main difference between the patients and their nurses was in the diet. The patients consumed a monotonous corn-based diet, while the nurses ate a nutritious and varied diet. Searcy was aware of the literature implicating consumption of damaged corn as the cause of pellagra among the Europeans. Hence, Searcy blamed the consumption of moldy and spoiled corn as the cause of the devastating epidemic. A sample of the cornmeal consumed at Mount Vernon Hospital was tested in a laboratory of plant pathology in Washington, DC, and was found to be unsuitable for human consumption.[7]

Soon after Searcy's report from Alabama, pellagra began to occur in epidemic proportions in several other mental institutions in the neighboring southern states. In 1909, an outbreak of pellagra was observed at the Peoria State Mental Hospital (Peoria, Ill). Occurrence of pellagra as far west as Illinois surprised most physicians,[8] and the pellagra epidemic was not confined to the mental institutions. The epidemic was seen in orphanages, cotton mill villages, and urban and rural areas.[8] Sir William Osler had stated in his first six editions of The Principles and Practice of Medicine (1892 to 1907) that pellagra had not been observed in the United States.[2] It is possible that pellagra could have been endemic among the vulnerable populations but had not been recognized. In a retrospective survey of physicians who had entered practice before 1903 in Spartanburg, SC, Wheeler[9] found that nearly 50% of the 62 practitioners surveyed had seen cases similar to pellagra before 1906. In that study, the earliest observed case of pellagra-like illness was in 1885. Wheeler speculated that "out of respect for authority" the previous generation of physicians did not venture to diagnose pellagra, since it was considered nonexistent in the United States. Babcock[8] reviewed the case records of the South Carolina Hospital for the Insane and concluded that pellagra-like illness existed among the inmates as early as 1834.

To the American physician and public alike, pellagra was a mysterious disease. The exact cause or cure for pellagra was not known. In Europe, pellagra had been in existence for nearly two centuries. Europeans had recognized the association of corn and the occurrence of pellagra. Although it had been opined that lack of some nutrient in corn caused pellagra, the commonly held opinion was that consumption of spoiled corn was responsible for pellagra. The "spoiled corn" theory proponents ascribed to pellagra the toxins liberated from mold infestation of corn, similar to the cause of ergotism by toxins in moldy rye.[4]

James Woods Babcock, MD, superintendent of the South Carolina Hospital for the Insane, was one of the pioneers in the study of pellagra in the United States.[10] In 1908, Babcock traveled to Italy with South Carolina Senator Tillman and visited several hospitals for pellagrins. Babcock returned convinced that "Italian pellagra" was similar to the cases of pellagra in the American South. On his return, Babcock studied the cases of pellagra among the inmates of his hospital and became a well-known pellagra consultant locally and nationally. Babcock organized the first National Conference of Pellagra in Columbia, SC, during November 1909. The conference was well-attended and well-received by the media. The conference strongly implicated corn, especially spoiled corn, in the etiology of pellagra.[8,11]

Indictment of corn created significant economic repercussions for agriculturists.[8] Corn was the main cash crop across the country. The southern states blamed the mechanized harvesting techniques of the western farmers for the spoilage of corn.[12] In the South, corn was a relatively minor crop, and the farmers could afford to follow the traditional method of harvesting, where the whole fodder with the ears was pulled out and allowed to dry thoroughly before the husking of the corn.[8,12] In the West, increased production of corn and a concomitant shortage of labor led to the use of mechanical harvesters. In the mechanical method, the machine cut the corn stalks with the corn ears and made them into shocks, which prevented proper drying of the corn ears and readily encouraged the growth of fungus.[8,12] Several of the southern states passed corn inspection laws. The Georgia State Board of Health issued a warning to the public about the danger of consumption of western corn.[8] As corn was facing the wrath of a frustrated medical and lay community, several other factors were proposed to cause or predispose people to the development of pellagra. Other staple dietary constituents of the southerners, such as cottonseed oil and sugar cane, were implicated.[8] Pellagra was deemed infectious by many and potentially heritable by some.[8]

The pellagra epidemic created a culture of "pellagraphobia."[13] Patients were shunned as "lepers" and ostracized.[8] The diagnosis of pellagra resulted in social isolation and despair for the affected. Some hospitals refused admission to pellagrins. Isolation of hospitalized pellagrins originated in Tennessee and became common practice in other southern states.[8] The unsuspecting patient was offered a plethora of unpleasant, illogical, and quixotic therapeutic options. Arsenic, salvarsan, calcium sulfide, iron, strychnine, quinine, autoserotherapy, partial appendectomy, and static electric shock were some of the prescribed therapies for pellagra.[8,14]

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