In August of 1862, two years before his infamous ‘March to the Sea’, General William T. Sherman declared, “Salt is eminently contraband.” The Southern leaders’ positioning of the South’s economy as dependent on cash crops created well-known shortages of many sorts. One aspect of this approach concerned the use of money acquired from cash crops to purchase food and salt. This failure and refusal to embrace a diverse, self-sufficient economy was a weakness seized upon by the Union that led to hunger and a return to a traditional but less healthy diet reliant on meat, meal, and molasses.[1] Opportunistic infections of many kinds present in the disease-infested South aggravated the plight of an already hungry and malnourished people. Many combinations of infections and conditions were far worse than the mere sum of the symptoms of those infections and conditions.

The scope of this paper is inadequate to embrace fully the subject of one disease in the South during the Civil War and Reconstruction, malaria. Typhus, especially typhoid fever, yellow fever, and dysentery were often grouped into “malarial fevers” during early research into the disease ecology present in the Civil War.[2] Easier to understand was the confusion between hookworm, starvation, and pellagra. When hookworm was eradicated early in the twentieth century, and the distinctively diseased nature of the South did not abate, answers would not be fully understandable until later when pellagra (niacin deficiency) was considered alongside starvation.[3] [4] However, addressing distinctive Southern diseases and conditions caused by, exacerbated by, or that became endemic by a lack of salt and other deprivations during the Civil War and “Reconstruction” should be remembered when discussing the Civil War. Otherwise, there is an inadequate context to examine the phenomenon of apathy and mental and/or developmental retardation in the South after the Civil War. There is also inadequate context of the cause and effects of plantation slavery concerning hookworm and other diseases before the Civil War. Examining the recent battles with the Necator americanus (American Killer) strain of hookworm in the Third World could help us understand the hookworm’s rise and devastating effects in the South during the Civil War.

Understanding history and science necessarily involves considering human beings as existing in nature. From the War of 1812 until 1860, there was a proven rise in both total income and per capita income in the United States. The expansion of plantation slavery led to the expansion of tropical disease populations introduced by black slaves. There was a general increase in the human and nonhuman population along with a general increase in population densities. The rise of cities further increased population density. The ability of infected (and asymptomatic) humans to travel, migrate, and trade dramatically increased due to the lowering of transportation costs. There was a lag between the increases in disease and parasitic morbidity associated with increased income and the “esoteric” pursuit of cures associated with increased income that were pursued instead of ascribing disease symptoms to “God’s will.”[5]

In explaining the spread of hookworm during the Civil War, understanding the solution to the antebellum paradox is helpful (see appendix). The greater ability to travel enabled infected people to better move from place to place, spreading disease as they went. The plantation system, with its close quarters and poor sanitation, provided an ongoing localized endemic reservoir of hookworm infestations. The increase of conglomerated urban centers, in providing a greater biomass, afforded greater opportunities for hookworms to infect humans. The general increase in population played a positive role in the spread of hookworm by providing more opportunities for infection, though not necessarily as positive as the dense population of cities. All these factors played a role in the dissemination of hookworm in the same way that disease in general played a role in the antebellum paradox. Discoveries of medical science had not caught up with the Industrial Revolution’s discoveries concerning travel and agriculture.[6]

Although Necator americanus was discovered in 1901, the study of disease pathology and parasitology became a distinct field of investigation by the late nineteenth century. In 1898, the identification of the mosquito as the carrier of malaria aided in removing the myths and confusion surrounding the disease. While not indigenous to the Americas, scientists concluded the Necator americanus hookworm came to the Western Hemisphere in the 17th century as part of the slave trade. Although discovered in the early 18th century in Europe, pellagra, unreported in the United States until 1902, was recognized to have reached epidemic levels in the American South by 1906.[7]

By 1902, many people thought that the “germ of laziness” that gave rise to the “disease of the cracker” was solved with the discovery of a new species of hookworm. This was not to be the case, as a number of different diseases with somewhat similar symptoms also existed in the South. The discovery of the etiology of pellagra proved to be elusive for years longer than anticipated. The story of the pellagra as a medical mystery predated the Civil War and continued long afterward. The status of the disease in the United States initially relegated it as an affliction suffered by those in the Old World. However, by 1920, the medical community increasingly referred to the South as the “land of hookworm and pellagra,” recognizing pellagra as relevant to the American South as well. With greater knowledge of pellagra in 1910, the famous researcher J. W. Babcock bravely risked impugning his practice by saying, “I know now that I should have made the diagnosis of pellagra in South Carolina nineteen years ago.”[8]

Pellagra is a nutritional disease that, alongside hookworm, can quickly lead to death. The little food that Southerners managed to acquire traditionally consisted of corn, molasses, and fatback. This created a situation ripe for contracting pellagra, which is caused by a deficiency of niacin caused by the meal (corn) not being treated to release niacin into the human system. With pellagra, there are the four Ds: dermatitis, delirium, diarrhea, and death. However, Kipple and Kipple in 1977 found references to “black tongue” and other diseases that led to the conclusion that pellagra was an issue in the antebellum South and beyond.[9]

A Focus on Contributory Factors to Southern Distinctiveness

Hookworm, starvation, malaria, and pellagra all share some of the same symptoms at different stages of their processes such as dementia, often leading doctors to misdiagnose disease. Modern science and the ongoing acquisition of knowledge of parasites and disease present a different interpretation of the effects of salt deprivation and hunger than is usually considered. An understanding of long-known social factors contributing to the disease ecology of the nineteenth century provides for a more accurate interpretation. The nineteenth century’s economic growth led to a doubling of population every 23 years and an increased density of cities. Successful investment made in transportation included canals, steamships, and railroads lowering the cost of people to travel and relocate. Parasites and pathogens once confined to regional and local areas were able to infect larger areas.[10]

Hookworms, discovered in 1838, acquired the name Ancylostoma Duodenale.[11] The discovery of the smaller species American Killer (Necator americanus) occurred in 1902 by Charles W. Stiles who convinced the Rockefeller Foundation to adopt a program to eradicate it from the South. Descendants of people from tropical West Africa have greater immunity and are better able to tolerate a given worm load than Northern Europeans. Though relatively more resistant, most black African slaves in the antebellum South were housed in groups of 20 or more providing dense environment for the spreading the disease. Slave infants were kept in crèches, providing a situation ripe for the spread of hookworm given an even more dense population. Infants and small children did not typically have shoes, further contributing to an ideal habitat for hookworm.[12]

Parasitic diseases of any sort have a devastating effect on mental development of children. Newborns utilize 87% of an adequate metabolic budget while five year olds utilize 44%.[13] When slave children were old enough and sent to work, their newly acquired shoes prevented further infection. Worm loads for working slaves would have tended to decrease, and childhood acquired immunity may have contributed to a toleration of hookworms.[14]

The question should be asked: Does the fall of Vicksburg herald the rise of American Killer?[15] Did the salt famine result in the sluggishness and dim-wittedness induced by starvation, malnutrition, and the associated opportunistic diseases especially prevalent in the climes of the South? It may be that by this time worm loads had increased substantially among Southern soldiers and civilians. From the outset of the war, there was an increase in contact with people from other areas of the South. Improper hygienic practices and a lack of shoes were widespread in the South from the beginning of the war, and the lack of salt used to make shoe leather made the problem worse. These three factors may well have led to a substantial increase in American Killer worm loads among the people of the South by this time. If American Killer worm loads consisted of over a hundred members in a large number of Southern children at this time, there is good reason to suspect that they would have suffered permanent physical developmental retardation and permanent mental developmental retardation as well. American Killer rose out of the Civil War as a serious plague among the Southern people, and a viable cure was not implemented until the first decade of the twentieth century.[16] [17]

The scientific attempt to understand truths concerning intelligence for groups and individuals is often difficult. Intelligence testing and the science involved is a very complex subject and studies concerning it are usually controversial. However, intelligence affects the lives of people. Pragmatically, the armed forces of the United States do not admit anyone with an intelligence quotient below 83. People with an intelligence quotient of under 83, generally affected by their intelligence in a way that others are not, tragically must make different life decisions.[18] Very significant mental retardation indicated by intelligence quotients of 76 occur in heavy (over 500) populations of hookworms in human children. Children with moderate worm loads of 100 to 500 have an average intelligence quotient of 84. Considering other factors such as genetic and environmental factors of intelligence, even the moderate effect of hookworms on the mental development attains an obvious vital importance. The infection of the South’s children with hookworm must have profoundly affected many residents.[19]

There is evidence that hookworms were not endemic in the South before 1860, but became epidemic during the 1860s. Otherwise, counterintuitive evidence suggest hookworms were the cause of lower production of cash crops from land with sandy soil in the South and higher production in areas of the South with clay soil. Agricultural productivity increased dramatically in the early 1910s after successes in the eradication of hookworms, though 740 million people in the world carried hookworms as late as 2006. Hookworm killed one million people in the South every year and lowered agricultural workers’ output between 40% to 60%. [20] [21]

It takes little imagination to determine what happened concerning the spread of hookworm in the Civil War. Suppose there was one black slave per Southern brigade brought along as a servant or cook. This servant, infected with one reproducing hookworm that produces 9,000 to 10,000 eggs per day,[22] defecates and infects an area of sandy, moist soil. The brigade camps for several days in an area of sandy soil and it rains, providing an opportunity for hookworms to hatch. Ten white soldiers lacking proper shoes, who would have lower resistance to hookworm, acquire “camp itch.” Their feet itch due to the initial infection of hookworm. It would not be long before these soldiers (infected with multiple reproducing female hookworms) brought this infection to many other soldiers, who might have ended up with only one reproducing female. One hookworm early in the war would be enough at this point in the scenario to validate the renowned Thomas Dionysius Clark statement:

Southerners are not what they used to be. Pick one out at random and he is stronger and more virile than his grandfather was. By modern American military standards of physical, mental, and moral fitness, however, more than half the Johnny Rebs who shelled the woods at Shiloh, Chancellorsville and Gettysburg, or stood with Pemberton at Vicksburg, might have been kept home as 4F’s. No one can say how much pellagra and hookworm helped sustain the Union…. Malaria fought on both sides….[23]

It takes little originality to imagine the above because of a similar imagined scenario for the transmission of hookworms in 1914 described by Jno. A. Ferrell, MD in The Rural School and Hookworm Disease. He presents the thought experiment of a school district not infected by hookworm. He then supposes that Mr. and Mrs. Smith visit an area with their son and daughter and pick strawberries while barefoot. After returning to their home (which is without a sanitary privy), the soil becomes infected and the entire family contracts hookworm. The children attend school with no sanitary privy, and the children hide behind the same bushes when toileting. Because these children are barefoot on infected soil, soon most students in the school have hookworm and then spread the disease to their homes.

Evidence of the Civil War decade as the beginning of the epidemic hookworm infestation of the South consists of four types, according to Garland Brinkley in “The Decline in Southern Agricultural Output, 1860-1880.” Two comparisons between antebellum and postbellum data are the increase in mortality and morbidity in postbellum data, and skeletal remains indicating anemia in postbellum data. Studies considering the hookworm infections, from 1860 to much later on, families dependent on subsistence farming consistently reveal that hookworm infections seriously reduce the ability to perform work. The use of skeletal data is particularly telling as it is absent the bias found in historical literature. The study of skeletal data that Brinkley referred to indicated greater mortality and morbidity during the postbellum years but did not consider a change in infection rates of hookworm during the Civil War.[24]

Confederate medical personnel noted symptoms of hookworm even though they did not know the cause. Three fourths of all discharges of Confederate soldiers in the first year of the war consisted of poor whites unfit for military service who spread disease among other soldiers. Rural antebellum Southerners defecated wherever and whenever the need arose. This was not a problem in transmitting hookworm, however, because only family members, who were generally not infected with hookworm, encountered feces, contaminated soil. Shoes were in very short supply for both soldiers and civilians, and the shortage of shoes was the greatest shortage of all articles of clothing. Multiple generals complained that thousands of their men had no shoes, while this complaint was largely absent by comparison to Union armies. The hookworm symptom now known as “ground itch” was so extremely pervasive among Southern troops that the symptom “camp itch” was more pervasive than any other affliction. It only took one soldier with one hookworm laying 5000 to 20,000 eggs per day to transmit the disease to many other, shoeless soldiers, who in turn would infect many other soldiers. Salt, needed to tan leather, had a higher priority in food preservation than tanning. As a result, Southerners suffered a shortage of shoes to dramatic effect.[25]

Charles Stiles, the discoverer of American Killer, noted 1,213,685 cases of “malarial fevers” from 1861 to 1866 among Southern troops. Often, such fevers went unreported. Hookworm, rather than typhus or malaria, best accounts for the low death toll of only 12,199 and also for the symptoms of diarrhea, fever, and fatigue. Southern army doctors recognized the link between fatigue and the absence of shoes, calling shoeless soldiers “malingerers” on numerous occasions.[26]

Brinkley suggests that unsanitary conditions and lack of provisions may have contributed to a legacy of an increase in hookworm during the Civil War that continued, “long after the guns went silent,” but there are other conditions and diseases that merit consideration.[27] In addition, having two diseases can create a situation that synergistically has negative impacts worse than the combined symptoms of each disease considered separately, like pellagra and hookworm together.[28]

For poor people of the South, the three Ms (meal, meat, and molasses), known since the South was a frontier, continued as a diet into the nineteenth and twentieth centuries. Affluent Southerners and people from the North did not pursue this diet. For poor Southerners, this diet was ideal because the components did not spoil, did not cost much, preparation was quick, and the combination was filling. The symptoms of pellagra are dementia, diarrhea, dermatitis, and death. This disease, recognized as a big problem in the South in the twentieth century among institutionalized Southerners, with symptoms indicative of pellagra date back to the Civil War and antebellum era as well among slaves.[29]

In the twentieth century, many theories of the causes of pellagra were entertained. Pellagra primarily affected the poor. Because of the perception of the poor as being filthy, Joseph Goldberger even held filth parties and injected his wife with scabs from pellagra sores, or “filth,” in one instance in a successful attempt to rule out filth as a cause for pellagra. Pellagra is a nutritional disease, whereas hookworm has an association with fecal contamination. In 1916, W. J. Kerr declared that pellagra, not tuberculosis, was the cause of so many deaths at the Andersonville, Georgia POW camp during the Civil War. Dr. Drisdelle attributes one third of the deaths to hookworm. It may be that many had both pellagra and hookworm in addition to starvation.[30] [31]

The late nineteenth and early twentieth century are unique in that the linkage was broken between population growth, economic expansion, and a deteriorating disease environment. The dedication to the discovery of scientific truth pursued by people like Goldberger illustrates how this breakage came about, but brings into focus the questions of what the disease environment was at that time, and what the disease environment and disease ecology was in the decades leading up to it.[32]

Of the four types of malaria, Plasmodium falciparum is the most deadly and therefore the most likely to affect reproductive rates. Plasmodium falciparum became a problem for the South and merits attention as a part of the disease ecology associated with the South. Like hookworm and yellow fever, many people with ancestry in Northwest Africa have a genetic immunity to malaria. Though often confused with hookworm, pellagra, and other diseases, malaria is a complex and unique disease.[33]

The germ theory of medicine was in its infancy from 1860 to the middle 1880s. Instead, physicians received education in miasma theories of disease preferring explanations that readily offered remedies regardless of the remedies’ effectiveness. Miasma theories dated back to the Middle Ages and supported the view that bad air caused disease. However, the quinine treatment known in the antebellum period increased the survivability of a bout of malaria. Though malaria declined in the South and the Midwest after the Civil War, it remained a problem in the South until World War II. Throughout the nineteenth century, physicians misdiagnosed malaria based on perceptions of the North and South.[34] [35] [36]


The Civil War was won as a war of attrition. General Sherman’s recognition of this early in the war led to his assignment of salt as contraband due to its use in preserving meat. This in turn led to profound changes in the disease ecology of the South leading to endemic pellagra and hookworm that did not exist in the antebellum South. The symptom of delusion common to hookworm, pellagra, malaria, and starvation led to confused diagnoses while contributing to a long standing belief that Southern distinctiveness includes laziness, apathy, and dim-wittedness.

Appendix 1: Definition of Terms

“Antebellum Puzzle”: “Why did human heights decline as incomes rose between 1812 and 1860” in the United States?[37]

“Contraband”: Official records of the United States Navy contextually imply the definition to be any thing or being that may have human qualities possibly furthering the cause of the South. It may be that this term is better described than defined when the contraband are human.[38] For the purpose of this paper, it is enough to know that sometimes the contraband relayed information possibly considered reliable to some extent. Union officers varied in considerations of reliability of information acquired from contraband.

“Disease Ecology”: “The interaction of the behavior and ecology of hosts with the biology of pathogens, as it relates to the impact of diseases on populations.”[39]

“Miasma”: “A poisonous vapor or mist believed to be made up of particles from decomposing material that could cause disease and could be identified by its foul smell.”[40]


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[1] Akst, “The Forgotten Plague.”

[2] Hong, “The Burden of Early Exposure to Malaria.”

[3] Etheridge, “Pellagra” 100-116.

[4] Breeden, “Disease as a Factor,” 9-10.

[5] McGuire and Coelho, Parasites, 53-55, 217.

[6] Ibid, 53-55, 122, 141, 204.217.

[7] Breeden, “Disease as a Factor,” 14.

[8] Skelton, ““Poverty or Privies?”

[9] McGuire and Coelho, Parasites, 124, 127-128, 132.

[10] McGuire and Coelho, Parasites, 176-186.

[11] Pineda and Yang, “Hookworm.”

[12] McGuire and Coelho, Parasites, 149-154.

[13] Pineda and Yang, “Hookworm.”

[14] McGuire and Coelho, Parasites, 149-154.

[15] Clark, Three American Frontiers, 206.

[16] Drisdelle, Parasites, 76-79.

[17] McGuire and Coelho, 185. 207.

[18] Peterson, “The Neuroscience of Intelligence.”

[19] Smillie and Spencer, “Mental Retardation in School Children.”

[20] Brinkley, “The Economic Impact of Disease,” 372-373.

[21] Yang and Pineda, “Hookworm.”

[22] Ibid.

[23] Clark, Three American Frontiers, 206.

[24] Brinkley, “The Decline in Southern Agricultural Output,” 119-122.

[25] Ibid, 122-124.

[26] Brinkley, “The Decline in Southern Agricultural Output,” 124-125.

[27] Ibid, 125-133.

[28] McGuire and Coelho, Parasites, 132.

[29] Akst, “The Forgotten Plague,”

[30] Ibid.

[31] Drisdelle, Parasites, 86.

[32] McGuire and Coelho, 175.

[33] McGuire and Coelho, 88-91.

[34] Tomes, “American Attitudes,” 18.

[35] McGuire and Coelho, Parasites, 161.

[36] Downs, Sick From Freedom, 191

[37] Mcguire and Coelho, Parasites, 52-53.

[38] James, “Confederates of Color.”

[39] Colorado State University, “Disease Ecology.”.

[40] Shiel Jr., “Medical Definition of Miasma.”

Vann Boseman

Vann Boseman is an independent historian in Florida.

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