Topics in Public Health


Goldberger's War: The Life and Work of a Public Health Crusader ; The Puzzle of Pellagra.


Imagine that you a visiting a medical ward

in a hospital in rural Southern US,

Let's say Mississippi.... In 1915

The hospital is out in the country..... it is surrounded by corn fields

the locals are poor Black farm labourers... many of them children

They are so poor that their main cornpone

a flat loaf of cornmeal shaped by hand......made without milk or eggs

So as we make rounds in the hospital


Here is a patient over here, suffering from diarrhea..... He has a skin rash

One over here, admitted with a depression....he has a skin rash

Over here, a patient with dementia....waiting to admitted to the local asylum...

He also has a skin rash


Another patient he has just died....and he has a skin rash

The rash like a sun burn....but then the skin becomes dirty brown...

then rough and scaly...mostly in sun exposed areas....

the mouth is sore, the tongue is inflamed and beet red

What is wrong with all of these patients?

They have pellagra.....a word that means "rough skin"

Pellagra a disease

Characterized by the 5D's.... dermatitis , dysphagia, diarrhea, dementia and death


But What is the cause? This leads us to the interesting story

of Dr. Joseph Goldberger ........Who was a public health doctor

who discovered the cause off pellagra..... the "scourge of the south,"

Joseph Goldberger was the son of immigrant Orthodox Jewish parents

The family came to New York in 1883...... and settled on the Lower East Side.

At first he wanted to become an engineer ..and enrolled at the free City College,

He divided his time between studying..... and helping at his father's grocery store.***


But A neighbourhood Irish immigrant friend

introduced him ....To medical practice

and young Goldberger became hooked on medicine.

He entered... Bellevue Hospital Medical College,

he was further inspired by Dr Austin Flint ....who himself was a famous cardiologist

is was immortalized the Austin Flint Murmur

which is heart murmur heard in patients who have aortic valve disease

caused by syphilis or rheumatic fever

Goldberger graduated in 1895.

He passed the written and oral examinations

for the US Marine Hospital Service,

which in 1912... became the US Public Health Service

and he was commissioned as assistant surgeon.

His first post was as medical inspector

of newly arrived immigrants..... at the port of New York.



He was assigned to work under......Assistant surgeon Thomas Richardson

Who assigned Goldberger to a quarantine station,

where he learnt to recognise the signs ..... of various infectious diseases

... typhus, plague, cholera, and smallpox.

Richardson was..from a prominent southern family,

The two men became firm friends,..... and Richardson introduced Goldberger

to his cousin Mary........a beautiful young southern belle

who was grand niece of the Confederate leader Jefferson Davis.

Although both families were opposed to the idea....

The two were married in 1906........

Mary, shared his scientific curiosity,

She became the loyal supporter... of his medical research.


As we shall see

Goldberger's great opportunity arose when the surgeon general

assigned him to investigate pellagra.

By 1912 South Carolina alone had reported 30 000 cases,

with a death rate of 40%.


The prevailing view at that time... was that Pellagra was an Infectious disease

Goldberger (together with a group of volunteers)

Tested that theory ..... by ingesting bodily "materials"

from the bodies of people with pellagra

He even going so far as to inject his wife Mary ....with blood from patients.

None of the volunteers.....contracted the disease

Which suggested to G......that there was some other cause

His experience at his father's grocery story.... must have had an effect

He went on to do some careful feeding experiments

in Mississippi, At.... an orphans' home......

an insane asylum......... and a prison farm

He knew that corn was a staple of the southern diet for the poor

Corn is low in protein ..and in particular

It is deficient in amino acids.........tryptophane and lysine;

the amino acid Tryptophane is converted to the Vitamin Niacin in the body

As a result of his work.. Goldberger concluded that pellagra

was caused by a dietary deficiency.... of niacin

and could be cured by adding brewer's yeast....which contained lots of Niacin

to the diet of people with the deficiency.


Severely ill pellagrins had to be be treated an emergency,

specially those with diarrhea or dementia, as death could quickly follow

Niacin supplements would be given.....and

Mouth and gi symptoms..... improved within a day or two,

And unless irreversible brain damage had already occurred

demented patients become rational in 2-3 days,

It was quite miraculous


Goldberger was very aware social and economic factors ,

Which led to these nutritional deficiencies

So as a true public health physician

he campaigned vigorously ....against the real cause of pellagra

Which was the low wages of southern mill workers,

which prevented them from eating a balanced diet.


Dr Joseph Goldberger died of hypernephroma in 1929.

His portrait hangs in the director's office

at the National Institutes of Health in Bethesda, Maryland.

By the end of the century.......... in 1998,

when a medical audience in Charleston, South Carolina,

was asked how many ....had ever seen a case of pellagra

only a few of even the older physicians.... raised their hands.


from JAMA, Sept 2004