Pellagra: A revisionist approach

Abstract

H istory is rarely kind in its remembrances. Dimly remembered eponyms pepper the medical literature and, with the possible exception of teaching rounds, fade once again into obscurity. Three errors characterize the history of pellagra and have been perpetuated in the medical literature. Clarification of these three misconceptions is critical to the understanding of this now rare malady and its place in the history of medicine. Francoise Thiery is commonly credited with primacy in the clinical description of pellagra. He published his account in 1755 [l], antedating the publication of Gaspar Casal(1691-1759) in 1762 [2]. Casal described the illness, known as “ma1 de rosa” at that time, and recognized its connection to the importation of maize from the New World. This connection gave another name to pellagra-Asturian leprosy-named for a region in Northern Spain where maize was consumed. Casal recognized dementia as a prominent feature of pellagra and described “Casal’s necklace,” the sunburn-like lesions present around the collars of pellagrins. There is reasonable evidence to suggest that Thiery learned about Casal’s work at the Court and published his own observations. The error of crediting Thiery with the primal observation rather than simply the earliest publication persists. Casal seems to have been there first. The disease was named by Francesco Frapolli [3] in 1775, deriving the word from pell (skin) and agra (rough). Frapolli, like Casal, attributed the illness to the consumption of maize by the poor. In the United States, pellagra was not described until the beginning of the 19th century, when the southeast part of the country was widely affected. Sydenstricker noted that this extensive disease was related to the widespread use of the milling process on corn. Because of the prominent neurologic component, many of the victims of the disorder were placed in asylums for the insane. In Alabama, George Searcy [4] described 88 cases of pellagra with a mortality rate of 60 percent. E.D. Bondurant of the Medical Department of the Medical College in Mobile, the precursor of the University of South Alabama, provided histologic support for the report. Bondurant [5] subsequently wrote, “I contributed nothing material toward the making of the diagnosis, but I did become interested in the disease.” Bondurant [6] made further observations on the neurologic manifestations of pellagra in 1910, with the report of an additional 17 cases. Bondurant recognized the disease as connected with malnutrition. He wrote