The threat that pellagra once posed in the South is now largely and happily forgotten. But in the first three decades of the twentieth century it was on many southerners’ minds.

The threat that pellagra once posed in the South is now largely and happily forgotten. But in the first three decades of the twentieth century it was on many southerners’ minds. By the late 1920s, for no apparent reason, it was striking some 200,000 people a year, both white and black in about equal measure.

Though death claimed only about three percent of cases, pellagra’s ravages would have made many victims wish for an end. Known as the sickness of the four D’s–diarrhea, dermatitis, dementia, and death–its first sign was a reddening of areas commonly exposed to sun. Often confused with sunburn or poison oak, pellagra was indisputable when reddened skin crusted over and peeled, leaving splotched arms and telltale butterflylike lesions on the face. Over time, general malaise became serious depression and in the worst cases dementia, whose victims were commonly committed to (and often died in) asylums.

Such suffering, especially prevalent in textile mill villages, led to the convening in Columbia of three national conferences between 1909 and 1915, attended by health officers, scientists, and physicians. Their mission: discover pellagra’s cause, which could open a way to prevent and perhaps even cure it. The disease had been known in Mediterranean Europe since the mid–eighteenth century, but no one could work out its etiology. The favored theory was that it was caused by eating spoiled corn. And certainly the heavy reliance on grits and cornmeal by mill hands seemed to give that theory confirmation. But by the 1900s other ideas also found favor. Some saw an insect origin, while many others, such as South Carolina health officer James A. Hayne, argued for the presence of some undiscovered bacterium.

But pellagra’s root cause was not biological; it was economic. Southerners fell ill because they were poor and ate a diet heavy on salt pork, molasses, grits, and cornmeal but woefully deficient in foods known to prevent pellagra, such as eggs, milk and butter, fresh meat, and green vegetables. Chief advocate of this novel idea that the absence of something could cause disease was Joseph Goldberger, a Public Health Service epidemiologist and Hungarian immigrant. Because his notion assaulted southern pride and flew in the face of conventional wisdom, it faced a wall of opposition. But in a series of brilliant field researches in Mississippi and South Carolina from 1914 to 1916, his ideas won general, if grudging, acceptance.

Having shown pellagra’s tie to diet, Goldberger turned to a group of Spartanburg County mill villages to establish that poverty was the ruling link between the two. The connection was tragically clear: mill hands earning top wages showed a disease rate of only three and a half cases per thousand, while those earning the least–too little to buy preventive foods–had twelve times more pellagra. Especially troubling was the ten-times-higher rate among nonworking women within the textile industry. Pregnancy, Goldberger reasoned, was partly to blame, for the developing fetus would have undermined most women’s fragile nutritional stability. But the disparity also sprang from mill mothers’ habit of deferring pellagra-preventive foods to family workers.

Goldberger’s hypothesis became unarguable with America’s entry into World War I, which brought an economic upturn so robust that it lifted even mill operatives’ resources. By 1919 wages in the two Carolinas had vaulted 240 percent. Pellagra fell in equal measure, dropping by 1920 to its lowest level ever. Doctors in Spartanburg County, where Goldberger had worked, were so jubilant that they held a gala dinner to “bury pellagra.” Goldberger rejected such optimism and warned that if bad times returned, so would pellagra. And that soon happened: 1920 began a national depression that, along with the boll weevil, hit the cotton South uniquely hard. As cotton profits, prices, and wages fell, pellagra returned with a vengeance. In 1921 it started a climb that would go on for nearly a decade.

Yet if economic stagnation and pellagra looked to be permanent burdens, history pulled an unexpected surprise. In 1925 Goldberger discovered the miraculous curative powers of cheap, abundant brewer’s yeast. By the late 1920s an expanded network of local health departments was putting that discovery to use. South Carolina’s effort was typical: the health officer James Hayne finally got behind Goldberger and from 1928 to 1929 oversaw the disbursement of six tons of yeast through county health units to cure some 34,000 people. In the 1930s, even as economic conditions worsened, pellagra’s decline continued, thanks partly to Red Cross participation in yeast distribution but also (and ironically) to cotton’s further collapse. Farmers, now forced to diversify, began raising those pellagra-preventive foods for which they previously allotted no acreage. By 1940 pellagra had almost vanished from the South.

Sadly, Goldberger died in 1929 before these final victories. He also did not witness the solution of pellagra’s great mystery: its biological cause. In the late 1930s biochemists at the University of Wisconsin showed that it was the absence of niacin (a B vitamin) that unleashed the malady. Later work also proved the spoiled-corn theorists partly right. Corn diets lacked tryptophan, the vital ingredient in the body’s production of niacin.

Beardsley, Edward H. A History of Neglect: Health Care for Blacks and Mill Workers in the Twentieth-Century South. Knoxville: University of Tennessee Press, 1987.

Etheridge, Elizabeth. The Butterfly Caste: A Social History of Pellagra in the South. Westport, Conn.: Greenwood, 1972.

Goldberger, Joseph, et al. “A Study of the Relation of Family Income and Other Economic Factors to Pellagra Incidence in Seven Cotton Mill Villages of South Carolina.” Public Health Reports 35 (November 12, 1920): 2673–714.

Citation Information

The following information is provided for citations.

  • Title Pellagra
  • Coverage ?–1930s
  • Author
  • Keywords sickness of the four D’s—diarrhea, dermatitis, dementia, and death, Often confused with sunburn or poison oak, progresses into dementia, fatigue, depression, pellagra’s root cause was not biological; it was economic, concerned lack of nutrients in diet
  • Website Name South Carolina Encyclopedia
  • Publisher University of South Carolina, Institute for Southern Studies
  • URL
  • Access Date March 4, 2024
  • Original Published Date
  • Date of Last Update August 22, 2022
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