Doctor's Review: Medicine on the Move

November 22, 2017
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A need for niacin

How a vitamin deficiency disfigured and even killed countless country folk 100 years ago

These days, vitamin deficiencies are rare in the developed world. We know that eating a balanced diet helps the body gets what it needs in order to keep things running smoothly. Even when people don't eat well — and let's face it, many of your patients certainly fall into that category — the plus side of the food industry's addiction to additives has meant that essential nutrients are readily available in junk food (along with a plethora of not-so-healthy additives).

Ever since American physician David Marine (1880-1976) introduced the first "functional food" by adding iodine to salt to prevent goiters in 1924, effectively eliminating that and all other symptoms of iodine deficiency, public-health authorities and food manufacturers around the world have cooperated to ensure that people get the basic vitamins and minerals needed to prevent a wide variety of problems.

Though they never knew it, the scientists of yesteryear waged war on many diseases caused by vitamin deficiencies. Scurvy, probably the most infamous of them all, was solved by Scottish physician James Lind (1716-1794) in the mid 18th century. While searching for a cure to the condition which killed thousands of British sailors annually, Lind soon suspected that dietary changes might fix the problem.

He was ridiculed, of course. Nobody believed that something as simple as food could cure something like the dreaded scurvy. After much experimentation, he found that citrus fruits resulted in near-immediate improvements. Lind's critics eventually ate their words, and the newly juiced-up British fleet and their landlubbing counterparts would forever be known as "limeys." Of course, Lind never knew that it was vitamin C that the sickly sailors were craving.

In fact, the term vitamin didn't even exist until 1911, when it was coined by Casimir Funk (1884-1967), the great Polish-American biochemist who was one of the first to recognize the connection between vitamins and health. He investigated the causes of beriberi, a fatal disease causing nerve damage and, ultimately, heart failure, which is common in Asia and other places where the diet consists mainly of polished white rice. His work eventually led to conclusive proof that the disease is caused by a lack of the B vitamin thiamine, which exists in the husks of rice.

A Problem Called Pellagra
Around the same time Funk was working on the beriberi problem, another serious disease caused by vitamin deficiency — this one, from a lack of niacin — was raging closer to home. Though reports of people suffering similar symptoms stretched back to the 1820s, the year 1902 marked the first time a condition called pellagra was described in the United States. Within a decade or so, it had become a serious epidemic. Tens of thousands of cases were being reported annually, primarily in the South, with the mortality rate in some areas as high as 40 percent.

Pellagra was not a pretty disease. Defined by the so-called "Four Ds," for the unfortunate course it followed — dermatitis, diarrhea, dementia and death — sufferers could look forward to an excruciating progression, sometimes in as little as four or five years from initial diagnosis to final outcome. According to some estimates, three million people contracted pellagra in the US between 1907 and 1940, with 100,000 deaths.

But pellagra wasn't strictly an American phenomenon, nor was it a particularly new problem. The disease had been known by various other names for centuries. In Spain, where the first clinical description appeared in 1735, physician Don Gaspar Casal described mal de la rosa — for the hallmark symptom, an angry red rash — as being a common affliction among peasants in certain areas. It was also prevalent in Northern Italy. Milanese physician Francesco Frapoli was the first to call it pelle agra in 1771, from the Italian words for "skin" and "sour." It also appeared in isolated parts of Europe, Russia and Egypt. Some historians even posit that Romanians gone batty from pellagra may have been the source of the original vampire legends.

What did they all have in common? Sufferers were almost always poor, rural folk whose main dietary staple was grain, particularly maize. In the 18th and 19th centuries, scientists and laypeople alike were aware of the connection, and so for centuries, the disease was most often attributed to some sort of corn poisoning or spoilage.

Interestingly, maize-dependent native North and South American populations never suffered from pellagra (just as they nibbled on pine needles to prevent scurvy), since part of their cultivation technique involved soaking the corn in lime, releasing the bound niacin within it, a process which was never adopted by those who brought the crop to other parts of the world.

Leprosy Of The South
When pellagra hit America, however, the medical and scientific communities decided it was actually a contagious disease. In fact, since the dermatological symptoms were so pronounced and so devastating, it was often mistaken for leprosy. Sufferers were shunned and the public lived in terror of acquiring the hideous illness.

 

In 1914, the Surgeon General appointed Dr Joseph Goldberger (1874-1929) of the US Public Health Service to study the problem. Goldberger was born in Hungary, then moved to the States as a young boy, eventually completing his medical studies at New York's Bellevue Hospital Medical College in 1895. He joined what would later become the US Public Health Service in 1899, specializing in the study of infectious disease. So, when the time came, he was a natural choice to head up the investigation into pellagra. They sent him to the Deep South, where the disease was most prevalent.

At first, he simply observed those most at risk — poor people and patients in state-run asylums and orphanages. He noticed the impoverished sharecroppers' diet consisted basically of cornbread and molasses. At the asylums, he found appalling conditions, with pellagrics left to rot and die, their open wounds festering and fly-covered, even their most basic med-ical needs ignored.

Goldberger wondered why their caregivers never developed the disease even though they spent years in close contact with patients. As the inmates were fed mostly corn, while the staff had a more balanced diet with meat, fruit and dairy, Goldberger discounted the prevailing wisdom and drew the conclusion that it was a diet-related illness. Nobody believed him.

Goldberger decided that the best way to prove his theory was to induce the disease through dietary changes. He turned to the prison population to make his point. A group of 11 incarcerated volunteers were recruited from Mississippi's Rankin State Prison Farm and offered full pardons if they agreed to take part in the experiment. Just as he expected, those prisoners who ate the traditional, corn-based diet of the poor displayed the typical pellagra rash within five months, while those who ate balanced meals remained symptom-free. Despite the fact that his study was sound, when he published his results Goldber-ger alienated more of his medical contemporaries than he won over.

Fear Factor, Circa 1916
To try once again to bring people over to his way of thinking, Goldberger, his wife and about a dozen other volunteers from the Public Health Service deliberately tried to infect themselves. In 1916, he held a series of what were aptly termed "filth parties" to achieve that end. And oh, what a delightful time they must have had.

First the volunteers feasted on scabs from the wounds of pellagrics. Then they injected themselves with vials full of the sufferers' blood. The revellers even swallowed gobs of their mucus and phlegm. Happily, nobody came down with anything more serious than a bad case of cooties. Goldberger's superiors and the public were still not impressed.

The doctor spent the rest of his life searching for exactly what it was that the corn-based diet lacked, that secret something so essential in the keeping pellagra at bay. Sadly, Goldberger never identified that it was a deficiency of the B vitamin niacin that was the direct cause of pellagra, nor did he live to see it happen. Instead, he tried to address the indirect cause of the problem, calling for social reform, public assistance for the poor and elimination of the poverty-inducing sharecropper system. Though pellagra incidence increased during times in which poverty was high, exactly as Goldberger predicted it would — such as those years in which cotton prices were low — nobody listened.

Of course, part of the reason Goldber-ger faced so much opposition was that, during the early 20th century, the scientific community was still enamoured with germ theory and eager to blame newly identified diseases, as well as a slew of old favourites, on the transmission of invisible microbes. But even more insidiously, American health authorities and politicians were reluctant to admit that poverty and one of its ugly stepchildren, poor diet, could be responsible for a disease epidemic.

Problem Solved
Then, as now, the idea of throwing a pill at the problem was far too tempting, and required far less effort than reducing poverty, educating an entire population and somehow providing them with healthier food. Goldberger wasn't vindicated until 1937, when American agricultural biochemist Conrad Elvehjem (1901-1962) identified niacin as a vitamin occurring in meat and yeast, and used it to cure pellagra.

Apart from the occasional raging alcoholic, the only kinds of dietary dearths seen by Western physicians nowadays are B-12 deficiencies in the tea-and-crumpet set, and anemia. The war against pellagra has been won, thanks to Dr Joseph Goldber-ger and enriched flour.

 

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