THE RHEUMATIC CHILD AND HIS WORLD

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SPECIAL ARTICLE

THE RHEUMATICCHILD AND HIS WORLD

An Ecologic Speculation

By Iago Galdston, M.D., F.A.P.A.

Executive Secretary, Committee on Medical Information, New York Academy of Medicine

I T IS PROVERBIALthat a fool can ask more

questions than a wise man can answer.

It is not proverbial that for the question asking fool there is some hope and for the others, none. Now it is my intention on this

occasion to play the fool awhile, to ask

a great number of questions, and I cordially invite you to join me in this game.

I want to inquire into The World of the

Rheumatic Child, into his internal as well

as into his external world, on, as Claude

Bernard has phrased it, into his milieu in terieur and into his milieu exterieur. Now

there is some method to my folly, and it

amounts to this. We know a great deal about the disease rheumatic fever and about its devastating effects within the body of

its victim. But we do not know a great deal,

indeed only a very little, about the vie

tim within whose body the disease effects

its devastations. I saidâ€”we know a great deal about the disease itself. In preparation for this talk I â€œ¿ne-surveyedthe literatureâ€• and I found it, as I have known it to be, not

only enormous in quantity but most impres

sive in quality. It is literally studded with masterpieces of etiobogic research, of clinical

surveys, of pathologic studies, of follow-up

surveys, of epidemiologic analyses, and of

therapeutic enterprises. In my review of the literature I came upon some old and es teemed friends whose works I had wit

nessed â€œ¿inthe making,â€• the studies, for ex

ample, of Wyckoff, and those of Alfred Cohn; Claire Ling's penetrating statistical

analyses, Pearl Raymond's biologic specu lations, May Wilson's classical and ency

ADDRESS:2 East103rdStreet,New York29,New York.

clopedic resume of knowledgeâ€”and U@OIi a host of others, too numerous, really, to catalogue. This refurbishing of old ac quaintances not only afforded me some

sorely needed reassurance, but also gave

me added warrant for the questions I want to ask. Thus Aifred Cohn, for example, tells us that the earliest statistical report on rheumatic fever is to be found in Havganth's monograph on acute rheumatism, published in England in 1805. This notation prompts me to askâ€”how old, how ancient, is rheu matic fever? I mean, in epidemic form. Does

this sound to you like an odd question?

Well, I assure you it isn't. It is assumed that all infectious diseases are as old as the human race. But not all infectious diseases are or have been prevalent throughout his

tory in the same order of spread and in tensity. Syphilis, for example, was unknown

in Europe before the time of Columbus, and leprosy which was rampant during the mid die ages â€œ¿burntitself out of its epidemic

proportions,â€• long before we knew its cause

or its treatment.1 Tuberculosis perhaps is the best example. Known throughout his tory, to the ancient Egyptians, to the Greeks in the days of Hippocrates, and to the Romans of Gaben's time, it was seemingly endemic in Europe for millenia, but it flared up in epidemic dimensions during the Sixteenth, Seventeenth, and Eighteenth

Centuries and did not begin to decline in spread and severity until the early decades of the Nineteenth Century.2 Is it possible,

then, that rheumatic fever too had been for long a sporadic disease, mildly endemic,

Address delivered at a conference on the Rheumatic Child and His World, November 13, 1956, sponsored by Irvington House for the care of children with heart disease, Irvington-on-Hudson, New York.

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SPECIAL ARTICLE

is reported by Dubos of the Rockefeller In

stitute.7 Tuberculosis was endemic in War

saw, Poland, long before the Nazis invaded

it. But among Warsaw's population the

Jewsconsistentlyhad a substantiallybower

tuberculosis death rate than did the Poles. When, however, the Nazis took over Poland, the Jewish population was singled out for

cruelty and starvation. The result was a

rapid rise in tuberculosis mortality among the Jews, fan greaten than that suffered by the Pobish population.

The virtue of the ecologic approach to the problem of diseaseâ€”and to health as webbâ€”isthat it encompasses the many fac

tons that affect disease, and well being, and

not only and merely the specific causative agents of disease. Therapeutically and prophylactically also, it broadens our means and methods. That is the reason why I'd like to suggest to you that you sponsor and slip port a study of inquiry into the epidemio logic history of rheumatic fever. Is it really ancient in its epidemic proportions, or is it, as I suspect, one of the Zivilisationsseti chen, that is a plague engendered by the advent of modern industrial civilization? Such a study might help us to assess the ecologic components in nheimmatic fever. It would tell us how, during the past 300 years, the world has changed for the nheu

matic child, and for all of us.

I made note of the fact that Thomas

Sydenharn, who lived in the Seventeenth Century, wrote on chorea. He also described

scarbatina, which was then an epidemic

disease. The Seventeenth Century seem ingly was an unhealthy age for the young.

The infant mortality was high. In Restona lion England sometimes half the births were wiped out by disease and two-fifths of the total deaths were of those under 2

years of age.9 Scarbatina was common, and

from 1776 on spread over both hemispheres. Diphtheria had been recognized by the ancients, under the name of ulcera Syniaca,

and was first competently described in the

Fifteenth Century by the Nunemberg city physician, Hartmann Schedel. But begin ning with the Fifteenth Century it was ex

amid that it became epidemic and severe in the Eighteenth Century? Is that why Hay garth felt warranted to compose a mono graph on the disease?3 On is it that you share the popular but erroneous idea that, if a disease had not been written about, time past, it was because the ancient doe tons weren't clever enough to recognize it?

If such be your beliefâ€”discard itâ€”for it is

essentially false. Let me quote you the words of a great physician, Richard Mead (1673-1754): â€œ¿Forit must be believed,â€• he wrote, â€œ¿thatthe first masters of our art who

are so careful in describing and distinguish

ing the signs of all diseases, would not have briefly mentioned them, but would have described them at length if they had but

known of these at once terrible and con

tagious diseases.@ It is noteworthy that

Thomas Sydenham (1624-1689) wrote on

chorea, and that Richard Bright (1789-1858) (lescnibed â€œ¿thebruit of the heart in chorea,â€• that is the association of heart murmur with chorea. William Pitcairn (1711-1791)

before him connected rheumatic fever with

heart disease.

@ The disease was seemingly

known and noted, but not as of epidemic Pr01)Ortions.

You might, of course, be tempted to ask â€œ¿wellwhat of it,â€•and thus force me to show my tricks as an ecologist. I'll anticipate your Protest (ltlestiomi, amid lay my â€œ¿handsbane.â€•

As an ecologist I book upon disease in a

somewhat different way than does, say the bacteriologist or the pathologist. I am more conceriied with the man sick than with the niaii's @â€˜¿ickness.And I argue that the man is sick not primarily because he has his sickness, but rather on the contrary, that he has his sickness because he is sick as an organism. The sickness is merely the symp toni of his fundamental illness. But the ill hess of the man, I would have you under

stand, need not be restricted to his being p1@cmp@@,it can reside as well in his en

vironment. Both he and his world, and most

likely 1)0th, may be in painful discord.6 Let me cite you a recent experience which

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penienced as an epidemic disease of fright ful devastation. The diarrheal diseases of in

fancy and childhood were among the lead

ing causes of death, down to the very be ginning of the present century.

Now you might properly ask what has

all this to do with rheumatic fever. Well,

scarlet fever, measles, and diphtheria, are

childhood diseases, and so is rheumatic fever. As an ecologist I am obliged to think not only of the childhood diseases but also of childhood itself. I am prompted to ask

is it not possible that the reason these child

hood diseases were so rampant and so malignant was because children were then in such miserably poor shape. I repeatâ€”is it not more than likely that they were sick not because they were diseased, but rather diseased because they were sick. They were,

as I prefer to phrase itâ€”disease prone. On

these scores, may I assure you, I am indulg

ing in a minimum of speculation. We know

a great deal about what happened to people â€”¿toboth adults and children, during the

past three centuries. We know that with the

advent of industrialization, which in Eng

land dates from the time of the enclosures,

great masses of people were torn away from the soil, were crowded into slum

factory towns, were inadequately fed on

miserable foods, and were overworked. If

you would know what happened in detail,

read the Hammonds on the town and vil

lage laboren,bo and if you believe that the

Umiited States was any better off, I urge you to read Stephen Smith's The City That Was,t1 and that city was New York. Pen

haps you believe â€œ¿that'sall in the past.â€• If you do, may I invite you to saunter with me,

on the way to The New York Academy of Medicine, say from Lexington Avenue to Fifth Avenue, on 103rd Street, New York. But an ecologic upset must not always be equated to poverty. An ecologic de gradation may occur even in the presence of plenty and affluence. The children of the wealthy may also develop rheumatic fever. Ecology is not a subdivision of economics. It is essentially a biologic disciplineâ€”with the emphasis on bios, the intricate ad

venture of living in and with the world. Rheumatic fever is, as you know, an in tniguing and puzzling disease. Its cause if it has a cause, remains unknown. It is

seemingly triggered on precipitated by

hemolytic streptococcus infection. It is a constitutional diseaseâ€”that is the entire economy of the child's being is involved, even though certain systems or organs may

seemingly be the sites of particularly in tense pathologic changes. The pathologic

reactions associated with rheumatic fever are in themselves soniewhat uniqueâ€”they center about what we call the reticubo endothebiab system. That system is com

posed of the connective tissues and the

lining membranes of the body. For a long time it was believed that these were the passive and sluggish members of the his tobogic family, not as important or as tive as say, nerve tissue, or muscle and gland cells, and serving merely to bind and support the other cells of the body. Then Aschoff12 taught us better. The reticubo endothelial system we now know is in volved in the immunity reactions of the

body. And here is a provocative idea. There

are quite a number of clinicians and re search workers who book upon rheumatic fever as an allergic disorder. Something

is untoward in the sufferer's reaction to the

provocative allergen. I will cite you an analogy to help you grasp the point. House dust is ever present in every house. You and

I may breathe it in with impunity. But there

are some people who are allergic to house

dust, and when they breathe it in they may

develop asthma and other distressing symp

toms.

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host of specialists, drawn from the major biologic and social disciplines. The most (lifficult and challenging task would be to formulate and to structure the study, rather than to execute it. This proposed study, however, has an illustrious precedent in Sin James Spence's study of 1,000 families in

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This then brings me to another phase of the ecology of rheumatic fever: the

familial. The high familial incidence of

rheumatic fever is striking and has been re ported on by numerous investigators. Some are persuaded that the familial frequency of the disease can be attributed to heredi tany, that is to genetic factors. May Wilson

is of that opinion. That may be possibly so,

and then again it may not. Heredity em braces more than genetics. I recall that we faced a similar problem in relation to

tuberculosis. But be that as it may. The family of the child with rheumatic fever

affords us a fine opportunity to test out some of our ecologic hypotheses. As the

siblings of the patient with rheumatic fever

are known to be more than commonly likely to develop rheumatic fever, we might en deavor to reduce this likelihood in a series of webb-formulated and webb-controlled studies, centered not primarily upon the children alone, but on the family totality.

I cannot of course offer you a scheme or plan for such a study, save only that it

shotmkl, to my mind, eschew as fan as pos

sible the so-cabled chemical or drug pro phybaxis of rheumatic fever. I would prefer

biologic to chemical or drug prophylaxis. This, of course, precipitously plunges me into the center of what I am afraid may seem to you like a â€œ¿hotissue.â€•I mean the drug prophylaxis of rheumatic fever. Ecobo

gists, however, are used to hot issues, and besides, if you look at it coldly, it doesn't seem so hot. Let me approach the matter

from the periphery toward the core. From the point of view of mortality, rheumatic fever has been greatly controlled during the past 40 years. In 1910, the death rate for rheumatic fever was 6.8 per 100,000 population. By 1920 it was reduced to 4.1.

victim? And does it not then follow that we need to turn our attention to the being of

the rheuniatic victim, and to see how it

may be affected, independent and apart from the disease? That would be an eco logic approach to the problem. Incidentally

I wonder if any one has attempted to treat the acute phase of rheumatic fever with

cnyothenapy, that is to â€œ¿freezeâ€•the patient, and thus to reduce his metabolic and re active intensity.

I know that the antihistaminic drugs have been tried, without notable results, but I think that's too mild an enterprise. This suggestion bears on therapy, and yet it is

hOt specific l)ut constitutional therapy. It is

only temporarily and transiently ecologic.

Not until we can permanently and funda

mentally affect the constitution, and the

milieu exterieur, that is the environment, of

the rheumatic child, may we hope to effec

tively reduce his disease proneness.

But any effort to affect the constitution of

the rheumatic fever child must begin with a

definition of the constitution â€œ¿asis.â€•I am hot even sure that there is a typical rheu matic fever constitution, even though clini cians have opined as much, describing the

rheumatic fever child as uncommonly sen

sitive. T. Duickett Jones wrote: â€œ¿Itis well

known that rheumatic fever patients show a nianked mionspecific hypenirnitability to

many stimuli. Although attacks are usually

precipitated by streptococcab throat infec tions, they may also follow trauma, sungi

cab operations, exposure to cold and even nonspecific protein shock reactions.â€•@@

My point, on rather question is this: Would it not profit us to really get to know the make-up of this â€œ¿marked,nonspecific hy

penirnitableâ€• constitution of the rheumatic

fever patient? It might help us to discover

wherein lies his disease proneness. In such

a study, which should be primarily an

thropometric, biochemical, physiologic, nu

tritional,and hygienic,I would not miss out

on the psychometric and the psychiatric.

The psychological can and does affect the organic. I need hardly add that such a

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In 1930 it was 2.5, and in 1950 it stood at

1.3 per 100,000 population and it is re

ported that between 1953 and 1954 there

was a 33@ reduction in the death rate from rheumatic fever, in the age groump from 10

to 14 years. Interestingly enough, I found that in 1940 the rate was likewise 0.8, and even bower in 1947 and in 1948, that is 0.7.

It more than doubled the following year, i.e., in 1949, when it stood at 1.6. The last

time it stood at that level was in 1937.15

Now you will forgive me for burdening yoti with so many statisticsâ€”but I require

them to make a pointâ€”and that is that death rates are not the best non the most ibluminat ing index to the well being of a people. To underscore this pointâ€”observe that in 1954, 16,392 deaths were charged to all forms of tuberculosis and 18,256 deaths to chronic

rheumatic heart disease.1Â° To this figure should be added 1,297 deaths due to rheu

matic fever. Yet what does this mean other than in terms of individual tragedy and bereavement? Grievous enoughâ€”it is true! But from the ecologic point of view I

would rather know how many living suf

feners do we have amongst our people, and how are they living out their livesâ€”effec

tively, on as a burden to themselves and to society?

My point is that bow mortality rates and

the patent effects of chemical prophybaxis are likely to give us a false sense of security

and achievement. Mind you I do not doubt

that we have made progress against the disease rheumatic fever. That progress, to

my mind, is mainly due to improvement in

living conditionsâ€”that is in the ecologic factors. Should they worsen we are likely to experience a resurgence of the disease. Chemical prophylaxis, too, has its rationale and its utility, but chiefly as a therapeutic shield or crutch. It does not and cannot directly influence the crucial factor in the rheumatic fever complex, that is the pen son of the victim. If it didâ€”then we would

be forced to conclude that the reason the

individual is sick is because he is lacking the chemical prophylactic. That, of course,

would be sheer nonsense. The subfona mides and antibiotics cannot be equated to insulin or thyroxmn. They are not agents of replacement therapy. Yet it cannot be doubted that chemical prophylaxis is

effective in reducing the recurrence of acute

attacks of the disease. I am, however, cnn

ous to knowâ€”is the disease perchance

driven underground, as happemis sometimes when subversive groups are suppressed? It

is likely to be existing in a subclinical form,

smoldering rather than flaming.

Of course, I do not know. I wonder if

the others do, and if not, is not this a some

thing to be booked into. A good ecologist

would! Indeed a good ecologist would want to have a long look at the rheumatic fever vicitim and at his life and experiences. He'd want both a profile and a longitudinal study of the patient. It is a somethimig to know that a certain percentile of rheumatic fever victims live for so many yearsâ€”and, â€œ¿quotes,â€•are working. It is good to know, as one researcher reported, that x number of females survived their rheumatic fever attacks in childhood, and that @â€˜¿number

married, and gave birth to children. But

life has many more dimensions thami (lura tion and before adjudging the trume sig nificance of a declining death rate, or the abiding and fundamental value of chemical prophylaxis, on of any enviromimentab on ecologic changes, I would want to kmiow, and to assess, their effects upon the total being of the patient in his living experience.

In these connections too I would recom

mend that you contemplate making Some profile, bong time studies of patients with rheumatic fever, to discover, if you please, what really happens to them in lifeâ€”both in spite of and because of their disease.

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process that must set the pattern for other

voluntary organizations and for medicine

entire.

It is too bateâ€”and time will not allow

me to elaborate upon this last point; hence

I can only treat it summarily. We are, as

VOtI must be aware, facing some revolu tionary changes in medicine. These involve not only the economics and the methodob ogies of medical practice, but even more profoundly, the ideational orientations of medicine itself.'@ We are coming to the end of the era (luring which the physician's chief

obligation, his professional commitment, tnd his I)ersonab and professional rewards,

lie in fighting disease. He is coming round

to the point, or rather not the practitioner

but biologic science is coming to the point, where the compelling evidence points to the conclumsion that fighting diseaseâ€”qua diseaseâ€”offers only a partial and a tempor any, l)uit never a substantial solution to the

problem of disease among the people.

Surely we must fight injury and infection, an(l mitigate disease wherever, whenever, and howsoever we can. But to help our peo pie to l)e @vell,we must help and guide them

to l)e less disease prone. And this invobves

vastly more than vaccines, serums, en

docrimie I)r0(ltmcts, antibiotics, and the mar @elsof surgery. It involves, what I have referred to as ecologic medicine, and under standing, amid treatmentâ€”on a physiologic rather than pathologic basis of man's reba tions to humnself and to his world about him. This soumids like an enormous, bike an over

whebming task for medicine. But it need miot be. Already we can perceive some ob

stetnicians and many pediatricians practic ing this type of medicine. As it would be physiologically rather than pathologically oriented, it should in effect be simple to practice. It is indeed easier to prescribe an

effective diet than it is to treat a man for

scurvy, rickets, pellagra, night blindness,

beriberi,hypoprotemnemia, and the rest of

the ugly host of nutritional diseases. Of course it will take more than the prescribing to get the diet to and into the man. That is

why we call it ecologicâ€”or as I prefer it,

Social Medicineâ€”and not merely physio logic medicine.

This, I am persuaded, charts the future of medicine, and the future is being shaped not by wishful thinking but by compelling

necessity. I have said many a time and I

ITflhiStrepeat it here, even in relation to

rheumatic fever, that modern curative medi

cine largely serves to convent mortality into morbidity with the result that we are laden with an even increasing and crushing bun den of chronic illness.

Justa fewdaysago,I cameuponsupport

from unexpected quarters. Let me quote

you a passage from an address delivered

by Dr. Irvine H. Page at The New York

Academy of Medicine.1@ He was talking about the medical and surgical treatment of severe hypertension:

â€œ¿Enoughpatients,â€• said Page, â€œ¿with severe hypertensive disease are now being kept alive so that clinical manifestations of the vascular diseases are looming larger and banger. Certainly 15 years ago we (lid not see the bizarre mental and morphological disturbances we are now seeing due chiefly to keeping patients alive so much longer. Cenebrovascular disease is becoming quite

as important to treat as it is to lower blood

pressure. A new spate of problems is upon

us and a fresh approach needs to be taken.â€• I wonder how the declining mortality

rate in rheumatic fever is related to the rising mortality in heart diseaseâ€”and with that of chronic rheumatic heart disease.

You see thenâ€”while playing the foolâ€”I have invited you to l)e in on the birth of a new era in medicine.

REFERENCES

1. Hecker, J. F. C. : The Epidemics of The Middle Ages, translated by B. G. Babing ton. London, George Woodfall and Son, 1844.

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3. Haygarth, J. : A Clinical History of the

Acute Rheumatism, or Rheumatic Fever. London, Cadell and Davies, 1813.

4. Rolleston, J. D. : The History of the Acute

Exanthemata. London, Heineman, 1937.

5. Pitcairn's Lectures of 1788.

6. Galdston, I. : The epidemic constitution in historic perspective. Bull. New York Acad. Med., Second Series, 18:No. 9, 1942.

7. Dubos, R. J., and Dubos, J. : The White Plague, Tuberculosis, Man and Society.

Boston, Little, 1952.

8. Galdston, I. : Progress in Medicine. New

York, London, Knopf, 1940.

9. Garrison, F. H. : An Introduction to the

History of Medicine. W. E. Saunders,

Philadelphia, 1913.

10. Hammond, J. L., and Hammond, B.: The Village Labourer, and The Town Labourer. London, Longmans, 1920. 11. Smith, S.: The City That Was. New York,

Frank Albaben, 1911.

12. Aschoff, L.: Das Retikulo-endotheliale System, in VortrÃ¤ge Ã¼ber Pathobogie.

Jena, G. Fischer, 1925.

13. Bland, E. F., Jones, T. D.: The natural

history of rheumatic fever: A 20 year perspective. Ann. mt. Med., 37:1006,

1952.

14. Spence, James C., et at. : A Thousand

Families in Newcastle-upon-Tyne: An Approach to the Study of Health and

Illness in Children. London, Oxford, 1954.

15. Vital Statistics-Special Reports, 43:No. 16, Aug. 2, 1956. Rheumatic Fever. U.S.

Department of Health, Education, amid Welfare, Public Health Service, National Office of Vital Statistics.

16. Vital Statistics-Special Reports, National

Summaries, 44:No. 1, Feb. 29, 1956.

Mortality from Each Causeâ€”United States, 1952-54. U. S. Department of Health, Education, and Welfare, Public Health Service, National Office of Vital Statistics.

17. Galdston, I.: The Meanimig of Social Medi cine. Cambridge, Harvard, 1954. (Pub

lished for The Commonwealth Fund.) 18. Page, I. H.: A clinical evaluation of hyper

tensive agents. Bull. New York Acad.

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1957;19;916

Pediatrics

Iago Galdston