The Southern Medical Association met at Dallas from 8 to 11 November 1915. Goldberger’s paper on the orphanages and the asylum, “A Test of Diet in the Prevention of Pellagra,” was on the programme, and the Mississippi result was a week old and in every newspaper. The discussion that followed was printed in the association’s journal in January 1916, and it is the best record there is of what the physicians who treated pellagra thought when they first heard that a diet had made it. Goldberger was not in the room; Allen W. Freeman of the Public Health Service spoke for the Service. What follows is the discussion in the order the journal printed it, cut for length but not for sense.

The Dallas commission

The Dallas Medical and Surgical Society had appointed its own pellagra commission in August, after a clinic of twenty or twenty-five patients, and its chairman, Dr Allison, opened by reporting what it had found after “talking with a good many men who are doing the most work along this line.” “Taking everything into consideration, we have come to the conclusion that the ideas advanced and the experiments given by Dr. Joseph Goldberger of the Public Health Service are the most plausible and probably the only theory that has come anywhere near being proven.” A second report for the infectious side followed, setting the Thompson-McFadden Commission’s six villages and 861 families against Goldberger’s orphanages: “While Goldberger’s theory seems at this time to have eclipsed all the attention and consideration of the medical world and the public mind in general, satisfactory proof is yet lacking.”

Freeman, for the Service

“The work of the Thompson-McFadden Commission was most interesting and, from the standpoint of negative results, most important. It has seemed to me, however, unfortunate that the commission after doing so beautiful a piece of work, should have hazarded an opinion on the evidence which was presented.” Goldberger’s experiments “were to settle three points: First, could pellagra be prevented in institutions where it prevailed in epidemic form by changes in diet alone; secondly, could persons suffering from pellagra be cured, if not too far advanced, by a liberal and varied diet; thirdly, could pellagra be produced in a selected group of cases by a diet deficient in certain proteid elements.” All three had been answered. “Dr. Goldberger does not claim and does not pretend to prove that diet is the only factor in pellagra, but he has produced results which, it seems to me, we should either confirm or reject. We must either disprove his findings or attempt to put the regimen he recommends into effect.” He added, with some regret, that it was “perhaps, unfortunate that Goldberger, in his effort to be of the greatest possible service, announced his findings so soon.”

Roberts, of Atlanta

Stewart R. Roberts had written a book on pellagra and saw it die at Grady Hospital. “From the time that Casal in Spain first reported the disease in 1732 down to the present time, two chapters in regard to the disease have never been written,” the cause and the cure. “Pellagra seems to exert a peculiar charm over the mind of the man who investigates it and begins to study it. It is almost as if one were pursuing a rainbow.” He thought the Italians’ peas, beans and meat worked because “pellagra is a wasting disease, and the only food substance that the human system can make protoplasm out of is proteid food.” Of Goldberger: “I must say that I differ with his ability to produce the disease or to cure it. I would have to have much more evidence than has been submitted to us yet. We have had many theories advanced and no proofs.” And of the forty doctors in one Georgia county, half of whom were curing pellagra with mixtures of six drugs: “I regret to say that all these gentlemen have been far more fortunate in the results of their treatment than I have ever been.” “I am sorry that I have appeared to be blunt, but if America is ever to solve the problem of pellagra, it will be after we have come down from our American confidence and theories and have come down to absolute intellectual honesty, and finally work out somewhere, sometime, proof.”

Marchman, of Dallas

O. M. Marchman told the story as it had reached Texas, and his version has details that are nowhere in the Service’s reports: Brewer and Goldberger “called all the prisoners together, the State prisoners, and explained the whole situation to them”; “eleven sturdy, strong, healthy prisoners, most of them life-termers, consented”; “they were given to understand if they ventured into these experiments they must stick six months”; “they found they were growing weaker and weaker and paler and paler each day. The erythema began to develop on their hands, and great sores appeared upon the bodies of these eleven convicts. They appealed to the governor with tears in their eyes and through their friends to be relieved. Some of the letters stated that they would rather serve a thousand years in the penitentiary than to undergo one more week of torture. But Governor Brewer would not flinch.” He had the count as “six of the prisoners developed marked symptoms of the disease, and two or three others developed the disease,” and named two who did not: “The two Atkinsons were well nourished and, by the way, we know the history of the two brothers who were connected with a bank up there, were considered well-to-do people, and had always been well nourished. They did not develop any symptoms of the disease, so far as could be ascertained, but all others did.” Whatever the truth of that, his conclusion was generous: “If this experiment never does any more good than it has done and proves a failure ultimately, it will have some influence on us like that exerted by Koch in the study of tuberculosis.”

Eustis, of New Orleans

“I would like to defend Dr. Goldberger. I knew Dr. Roberts did not mean anything personal when he said he might be considered a little harsh. I have known Dr. Goldberger for ten years; I have been associated with him in yellow fever work, and I do not know of any man who is more thoroughly trained in a scientific way than he is. I have heard no evidence as yet to counteract the ideas of Dr. Goldberger. He has explained his ideas to me personally, and I may say that I am converted.” He wanted to know what else the convicts had shown besides a rash, and moved that Freeman be given time to tell them. Freeman could not: “I am sorry that I have not got the information you ask me to give you. The point of view from which Dr. Goldberger attacked the problem was one of pure epidemiology, and he relied, I think, upon the judgment of a great many men who have seen many cases of pellagra to make the clinical diagnosis.”

Stinson, of Chickasha

John E. Stinson of Oklahoma had seen his first case three years before, in “an old man, a bootlegger,” who lived in “a filthy shack” in a black neighbourhood and died in three weeks; within eight months another bootlegger a block away had it, and nine of the town’s twenty cases since had come within three blocks. “Undoubtedly the disease is infectious.” “I believe firmly that the disease is infectious and patients with it should be quarantined. My opinion is that there never has been a case of true pellagra cured on the face of God’s earth.”

Hayne, of Columbia

James A. Hayne was South Carolina’s health officer, and he had the deaths. “In South Carolina up to the present time we have had twelve hundred deaths from pellagra; that is an annual death rate of ninety per hundred thousand population,” against twenty-six for typhoid; “we have a disease that is rapidly spreading and our people are dying of it and are dying at a rate second only to tuberculosis.” Goldberger, he said, had doubted that the disease was really increasing, because an increase did not fit a dietary cause. Three weeks before, at a conference in South Carolina, Goldberger had read a paper and “did not then say that the etiology of pellagra was due entirely to diet.” “I saw Dr. Grimm in Spartanburg, who said to me not less than a month ago, ‘Doctor, I do not know the cause of pellagra, and I think probably it may yet be found in the laboratory.’ Those are the facts, and yet in coming to this meeting, while on the train, not in a scientific medical journal, not before a body of scientific men, I found it stated to the laity that the causation of pellagra has been settled in the lay press, although for one hundred and ten years scientific men have been endeavoring to find the true cause of the disease. I want to enter a protest.”

Lehmann, of Dallas; Herold, of Shreveport

J. R. Lehmann: “If it were the cause, why was not pellagra reported fifty years ago in this country? Has the diet of the people changed so remarkably? Pellagra has swept over this country very much the same as the boll weevil swept over it except in a reverse direction.”

A. A. Herold, health officer of Caddo Parish: “Like my friend, Dr. Eustis, I am a convert to the theory of diet as the principal causative factor in pellagra, and I will tell you briefly why.” In his parish the farms and the oil fields lay side by side, the oil fields had the worse sanitation and the more flies and mosquitoes, “and yet not one case of pellagra has been reported from the oil fields, but over two hundred cases have been reported from the agricultural region. Our explanation of that is this: The usual ration of the farmer is fat meat, cornmeal and some syrup. On the other hand, the roughnecks in the oil fields will not stand for poor rations. The merchants tell me that there is no use in buying cheap foodstuffs and trying to sell them to the men in the oil regions, as they will not buy them.”

Martin, of Hot Springs

E. H. Martin treated pellagra with arsenic, “cacodylate of soda, soamin, neosalvarsan or salvarsan,” and believed in the germ: “A disease which has been known for over two hundred years in Europe, but has been hitherto unknown here, and which has spread rapidly over this country as soon as introduced here is necessarily infectious. It would be just as absurd to try to prove that wet weather is the cause of the boll weevil as to try to prove that pellagra is due to unbalanced diet.” But: “It has been an axiom with me for several years that absolute prevention of pellagra can be secured by having two hundred dollars in the bank. I have never seen anybody contract pellagra, except during the first few years after the appearance of the disease, who had any money in the bank. If you do not believe that, think of how few have paid you.” “I always prescribe Dr. Goldberger’s diet list but do not regard it as the important part of the treatment. How can you forcibly feed a patient on meat and beans who comes to you drooling, with a sore mouth and tongue and with a stomach which will not retain or digest food and with diarrhea?”

Leroy, of Memphis; Parrish, of Fort Worth

Louis Leroy had supervised Tennessee’s board of health when the first cases came: one at the Baptist orphanage, then four, then eighteen. “We quarantined these cases, we fumigated, cleaned and swept. We put every one apart from the rest, and from that time on no other cases developed, except a nurse who took care of them developed the disease. With respect to the teaching we are putting out in the newspapers today: telling people that there is no danger of pellagra, except from poor food and cooking, is pernicious. (Applause.)”

C. C. Parrish answered Goldberger’s point about the Army and Navy: “the Army and Navy comprise the picked men of the nation,” and “there are no open closets in the Navy and none in the Army.” He had seen pellagra “in some of our richest families.” “The economic conditions of this country, we are ever ready to assert, have improved in the last fifteen or twenty years, but in spite of that pellagra in the last decade has increased to an alarming extent.”

What the journal concluded

The association’s journal, a month later, allowed the experiment everything but the conclusion. “There is no denying the correctness of this report or the ability of the physicians who made the diagnoses. Is it not enough? Is it not conclusive? No. Not quite. Inevitably the question arises: If a meager diet, if any kind of a diet, can cause the unmistakable symptom-complex we call pellagra, why was the disease unknown in so many regions now affected until the last twenty years? Poverty of diet has always been with us, but not pellagra. Misers have starved themselves and their families, but they did not develop pellagra. … If we had not found the germ of tuberculosis we might easily have thought that it was caused by ‘an unbalanced diet.’ It is entirely possible, and even probable, that some day a causative organism for pellagra may be discovered. Meanwhile let us rejoice that pellagra can be classed among the curable diseases.”

Sources

• “Discussion: Symposium on Pellagra,” Southern Medical Association, ninth annual meeting, Dallas, 8 to 11 November 1915, Southern Medical Journal 9 (1), January 1916, including the reports of the Pellagra Commission of the Dallas Medical and Surgical Society. All the speakers’ words above. archive.org
• “The Cause of Pellagra,” editorial note, Southern Medical Journal 8 (12), December 1915. The journal’s conclusion. archive.org