In June 1930, the New England Journal of Medicine published an article entitled “The 1930 Type of Polyneuritis.” It described an epidemic of paralytic illness that had first appeared in March that year. Onset of this condition was usually heralded by lower leg muscular pain and tingling, rapidly followed by weakness that often also involved the upper extremities. Distal deep tendon reflexes were diminished. Sensory function remained intact or was only minimally affected.
TOCP is thought to inhibit a neuroprotective esterase or phosphorylation of neuronal proteins that induces axonal degeneration
Patients seemed to be clustered in specific parts of the United States, especially the South and Midwest. Most were middle-aged men who were unemployed or worked as temporary laborers. The number of patients eventually involved was staggering. In Johnson City, TN, 600 men were stricken, representing three percent of the city's entire population. Cincinnati General Hospital admitted 400 patients with quadraparesis in a single six-month period. There were 690 cases in Topeka and another 500 in Wichita.
Although the patients' upper extremity weakness often resolved, by the time the epidemic ended in January 1931, many victims were left with permanent lower extremity weakness and paralysis. Some would never walk again without assistance. Several estimates, probably somewhat exaggerated, had as many as 50,000 patients paralyzed or partly so.
The original New England Journal of Medicine article concluded that “when the final chapter has been written tabulating the thousands of scattered cases coming on almost simultaneously from an unknown cause, it will constitute one of the strangest pages in recent medical history.” Coming out just three months after the beginning of the epidemic, that article was the first clinical description of this puzzling polyneuritis to appear in the medical literature. But it was not the first description to appear.
Three months earlier, in March 1930, two blues musicians from Mississippi recorded songs during a session in Grafton, WI, that clearly referred to this epidemic. In addition, Ishmon Bracey's “Jake Liquor Blues” and Tommy Johnson's “Alcohol and Jake Blues” pointed to the key epidemiological factor, the one activity that was common to all victims of this new paralytic illness: consumption of “Jake.”
Jamaica Ginger Extract
Jake was the popular street term for Jamaica ginger extract, a patent medicine that had been consumed since the 1860s without causing any problem except intoxication. Ingesting a few drops mixed with water was reputed to cure upper respiratory infections, menstrual disorders, and intestinal gas. Jake was sold in two-ounce bottles for about 50 cents each. Because the preparation contained as much as 80% ethanol by weight, each bottle had an alcohol content equivalent to four shots of whiskey.
As with many other patent medicines, Jake was used as an alcoholic beverage in areas of the country that had outlawed liquor. It was consumed even more widely after the 18th amendment to the Constitution brought on nationwide prohibition in January 1919.
Twelve songs about the Jake epidemic were commercially recorded in the 1930s. Many referred to the “Jake Walk,” a distinctive gait necessitated by a foot drop, in which the forward leg is lifted high to allow the foot to clear the ground. Bracey's “Jake Liquor Blues” presents a particularly vivid account of the ravages of this disease, including the impotence that affected some victims that was referred to as “limber leg” or “limber trouble.” (See box.)
Although the connection of paralytic illness to consumption of Jake was clear early on, one crucial mystery remained. Jake had been available since the mid-19th century without causing acute neurological deficits. What happened in 1930 to change this? Theories abounded. Although some claimed that Jake had been contaminated with lead, carbolic acid, arsenic, or nicotine, none of these toxins explained the clinical presentation of Jake victims. Finally, the Bureau of Prohibition at the U.S. Treasury Department identified an unusual substance that had previously been assumed to be non-toxic: triorthocresyl phosphate (TOCP).
TOCP is an organophosphate that, lacking significant anticholinesterase activity, is not effective as an insecticide. But it has several other uses. It is an additive in varnish, and is used extensively as an industrial plasticizer. It is an oily, clear, tasteless, and odorless liquid that retains lubricating properties at very high temperatures, and is used in aviation hydraulic fluid. Despite early claims that TOCP was safe, it is now known to be a classic cause of organophosphate-induced delayed neuropathy.
Although the mechanism through which TOCP causes neurological damage is not completely known, it is thought to involve inhibition of a neuroprotective esterase or phosphorylation of neuronal proteins. This induces axonal degeneration that initially presents as a motor neuropathy, later affecting the anterior horn cells and pyramidal tracts of the spinal cord, causing an upper motor neuron syndrome with spasticity and hyper-reflexia. When 11 survivors of Jake paralysis were tracked down 47 years after the acute illness, 10 had residual spasticity and abnormal gait. (Arch Neurol 1978;35:530.)
But why did TOCP suddenly appear in preparations of Jamaican ginger extract? Eventually all the contaminated bottles were traced back to a single producer in Boston, Hub Products, and its effort to defeat a Department of Agriculture test to ensure that its product complied with U.S.P. standards. In this test, the sample of Jake was heated until all the volatiles boiled off. A certain minimum weight of residual solid or resinous material remaining constituted an acceptable test.
This was intended to ensure that the preparation contained a high enough concentration of ginger to make it unpotable straight from the bottle. Previously castor oil had been used as an adulterant, but it became too expensive. Hub considered using ethylene glycol and diethylene glycol, but found that both were too volatile. They settled on TOCP.
The entire history of Jake paralysis is described in a fascinating New Yorker article by Dan Baum (Sept. 15, 2003). It is well worth searching out. “Jake Leg Blues,” a CD issued by Jass Records (J-CD-642), contains all 12 recorded blues and bluegrass songs referring to Jake paralysis. It is out of print, but occasionally available on Ebay. Willie Lofton's “Jake Leg Blues” can be heard on the web at the North Carolina Moonshine site, www.ibiblio.org/moonshine/drink/jake.html.
Doing the Jake Walk
Aunt Jane she came a runnin', tellin' everybody in the neighborhood,
Aunt Jane she came runnin' and screamin', tellin' everybody in the neighborhood,
‘That man of mine got the limber trouble, and his lovin' can't do me any good.'
“Jake Liquor Blues”