Sunday, May 02, 2010

Rheumatic Fever Understanding as of 1901

There is some mystery if Lovecraft had rheumatic fever, and if so when. There are only vague probabilities, and one scenario is thus... {sheer speculation}

Lovecraft attended school between the 2nd week of September 1898 and 30 June 1899. simultaneously he was taking violin lessons, and sundry other childhood activity.

Subsequent to that he reports that he spent the summer with his mother. It seems that a few times, just after his brithday, Susan and Howard went on vacation away from the hot city. It seems natural to think that this was no different, though others have went on record thinking it involved a breakdown.

The details of 1898-1899 are devilishly sparse, but some things we can try to deduce with some probability. He attended school with relatively little effect, enjoyed his summer, went on vacation, and returned. He might have, and probably did get strep throat and fever, but ther doctor got him trhough that. Certainly we do not hear of any tonsilectomy.

Chrispy does not think there was ever an intention of Lovecraft going to school after primary graduation. He would have had tutors again. His next session would have scheduled for graduation from grammar school years away - in 1902.

Sore throats can happen anytime, but they often happen at the turn of the Autumn season. Fall pollen can irritate dry tissues as the absolute humidity in New England drops dramatically sometime in early October. This makes the throat highly susceptible. {Chrispy was plagued by it as a child and even beyond his college years}.

He recovered from hsi sore throat, and went back to his school work. About 30-40 days or so later, the bacteria would have erupted in the manifestation of sore joints (arthritis), skin knots or lumps, a sore stomach, shortness of breath - and one can only imagine what Susan thought. Syphillis? The local doctor diagnosed a gall bladder attack for some odd reason - maybe simultaneously Lovecraft had a mild ulcer from his violin stress?

If this scenario happened as presented, then Thanksgiving and Christmas were wiped out by his recovery, and family panic.

One suspects that Dr. Clark quickly became involved, got a specialist's opinion, and treatment ensued of probably sodium bicarbonate and what we now know as "Ben-Gay" methyl salicylate, and perhaps aspirin (another salicylate). See the official state of the art below. He would have moved on crutches due to the excruciating pains, and had warm baths. In virtually all cases, the heart is dramatically affected.

Yes, this qualifies as a breakdown, but not a mental breakdown, a very physical one.

It would have taken a lot of recovery time, but by his birthday of 20 August 1900 he received a bicycle. This was not only a reward, a birthday persent, but also therapy to strengthn his heart.

The bacteria did not go away, and would come back - Chrispy thinks - in many forms. Chorea = St Vitus Dance, scarlet fever, and maybe chronic mild multiple sclerosis. There were long periods where Lovecraft was a physcial demon of bicycling, walking miles, building gardens, shoveling snow, and 1906 he was incredible. There were other times he collapsed. CM Eddy witnesed this on the trip to Chepatchet.

Late in life, he developed other odd symptoms, notably intolerance to cold. Yet as a youth, he seemed immune to this.

These are all odd symptoms, but there are some odds that favor form late 1899 onward he had pepetual streptococcus bacteria in his tissue that nagged him through his final years.

Thus ends one possible scenario of Lovecraft's childhood between late 1898 and mid-1900.

Read on for a 1901 state of the art discussion of rhematic fever.

The Cincinnati Lancet-Clinic
14 September 1901

Professor of Diseases of Children, Miami Medical College
As a text for some remarks upon this subject the following histories are submitted :
Ella Maloney, seven years of age, was brought to my office on April 2i, 1901. Her movements were so choreic that it was with difficulty she walked from the waiting-room into the consultation-room. Feet, hands, and facial muscles were in almost constant motion ; she was pale. The area of heart dullness was considerably enlarged ; pulsation violent; loud apex, systolic murmur ; temperature normal. The mother could recall that about three weeks previous the child had had painful joints and a little fever for a few days, but had received no treatment, not even having been in bed.
While visiting the child at her home the following day, I observed that Jimmie, her eleven year old brother, was twitching his right hand and arm. Examination of his heart revealed a mitral systolic mumur. The mother explained that he had been kept out of school " because he could not write his lessons." Close inquiry developed that he had also had fugitive joint pains a week or two previous. This boy was a badly developed child who had suffered severely from gastro-enteritis and convulsions in his infancy. In a few days his limbs and his facial muscles were involved. He did not make a complete recovery for about four months.
On May 9, Johnny, the ten year old brother, developed an inflammatory rheumatism involving an ankle and one knee, with a moderate temperature. He was kept in bed, given salicylates and alkalies. AH symptoms had subsided on the tenth day, and he was discharged on the twelfth day. This boy had no cardiac involvement and no chorea.
On June 15 James Maloney, the father, Iribh, aged thirty-five, driver of a patrolwagon, was taken with an attack of inflammatory rheumatism which involved several joints, was accompanied by high temperature, and confined him to his bed for several weeks. He had no heart lesion.
This family lived in a badly ventilated cottage with a damp cellar. The father and three children of a family of seven, ranging in ages from three to thirteen years, Ellen seven, Johnny ten, James eleven, were affected. Ella and James had only fugitive joint pains, little fever, severe endocarditis and the development of chorea. Johnny had severe arthritis, moderate fever, no endocarditis, no chorea. The father had very severe arthritis, high fever, no cardiac involvement, no chorea.
These histories suggest at least the probability of an infection, not necessarily from person to person, but in the surroundings. All our experiences contradict the belief in contagiousness from individual contact. Rheumatic patients lie side by side with other patients in the hospital ward with no spread of the disease. Attendants are not attacked with sufficient frequency to warrant the assumption of contagion. It has been suggested that the infecting agent in this disease lies buried deep in the tissues, and, therefore, is not conveyed by contact. Careful study of statistics reveals that the disease does, at times, prevail in epidemic form. The repeated occurrence in the same house or in the same neighborhoods would speak in favor of an infecting agent.
In a paper on " The Natural History of Rheumatic Fever," in the Lancet, March, 1895, Dr. A. Newsholm has well summed up these points. For instance, he quotes this statement from Dr. Fressinger : "In the vilLige of Ozounax there are about five hundred houses. In twelve dry and well-ventilated houses in one street, ten out of twenty-one cases of rheumatic fever have occurred in recent years. Of these ten four were in the same house and two in the same room. In the last instance there was a year's interval and members of different families were attacked."
* Read before the Academy of Medicine of Cincinnati, June 10, 1901.
Edelf&en gives these statistics from Kiel. There occurred—
Two cases in one house, . . too times.
Three cases in one house, . 27 times.
Four cases in one house, . . 5 times.
Five cases in one house, . . 5 times.
Six cases in one house, . . i time.
Seven cases in one house, . I time.
That this occurrence of numerous cases in the same house is not solely due to family proclivity is evident from the fact that those attacked are sometimes of different families. It has for a long time been the general belief, based upon the mode of its onset, its course and other resemblances, that rheumatism belongs to the acute infectious diseases. Diligent efforts have been made during the past ten years to discover the micro-organism responsible for the disease. Guttmann, in 1892, isolated the staphylococcus pyogenes from a case of rheumasism. Sahli obtained the staphylococcus pyogenes citreus from the synovial membranes and pericardial exudate. Dana, in 1894, isolated adiplococcus from a case of chorea followi'g rheumatism. The work which has attracted the most attention was probably that of Alchane, who, in a series of papers ( Comptes Rendus de la Soc. de Biologic, 1891) reported the finding of a bacillus resembling that of anthrax. The bacteriological findings have been so various that there is now a tendency to regard it as due to several micro-organisms. In the Lancet, September, 1900, Dr. F. J. Poynton and Dr. Alex. Paine, of London, reported the finding of a peculiar diplococcus in e:ght successive cases. They obtained a pure culture in five cases. They have isolated and prown them upon an acid medium and blood-agar. They demonstrated them upon cardiac valves, pericardium, tonsils, and in one nodule in a fatal case. They have produced, by inoculating rabbits, poly arthritis, fever, valvulttis and pericarditis. In the Lancet of May 4, 1901, they cont;nue their report, and state that
in sixteen successive cases they have isolated the diplococcus. The work of these gentlemen seems to have been most carefully carried out, and it may be that they have discovered the germ of the disease. Treboulet and Coyon report having found a diplococcus in all cases of rheumatism examined (Bull. Soc. des Hop., 1897).
The cases reported illustrate some of the well-known peculiarities of the disease in children. Of the three children, two, Ella and James, had such slight arthritic symptoms that they had attracted noaltention. They had had so little fever that, if present at all, it had been quite overlooked in one and in the second considered of no consequence ; yet both had severe endocarditis with permanent damage to the valves. The third had pronounced arthriiis and fever, yet had no endocarditis. Whether the fact that he was, on the first appearance of symptoms, put to bed and given active treatment may have prevented heart complications one cannot say, since in many cases so treated they still occur. It is probable, however, that this had some influence. The coincidence of the two cases of endocarditis with two cases of poly - arthritis assists in confirming the belief that the former was rheumatic in origin. That the endocarditis and pericarditis of early life are almost always of rheumatic origin is so well established that we need not stop to argue it. The infrequency of rheumatii-m in infancy and early childhood is partly to be accounted for by the fact that rheumatism, at this period of life, is so often si ght in its manifestations and so often has few or fugitive articular symptoms. Children illustrate well that rheumatism is not a local but a general diseate, the intensity of its local manifestations in various organs differing greatly in different cases. For this reason the term "rheumatic fever," used so much by English writers, is preferable to " acute articular rheumatism," and might well come into more general use in our own country.
The two cases which had endocarditis had also chorea. The arthritic case escaped chorea. This is in accordance with my experience, and I think with general experience, that chorea is more intimately associated with endocarditis than with arthritis. In every case of chorea which I have ever seen there has been a cardiac murmur. In 50 per cent, of the cases this

murmur was organic, as shown by its persistence after the cure of the chorea and the anemia. The close relationship of chorea to rheumatism seems to me certain, though I am well aware that s me writers still maintain a coincidence and not a causal dependence. My own limited experience quite agrees with the statement of Holt, in his text-book, that evidences of preceding rheumatism or of a distinct rheumatic diathesis can be obtained in more than half the cases. The fact that it is the cases which have endocarditis which are most frequently followed by chorea is capable of two interpretations : (i) That the endocarditis has a causal relationship to the chorea; (2) that the endocarditis and chorea are both evidence of the intensity and wide distribution of the infection. The chorea may appear before the rheumatism. "Whichever of the three conditions is first seen, the physician should always be on the lookout for the other two" (Holt).
The subcutaneous nodules, described in 1881 by Barlow and Warner, may assist the diagnosis in ob'cure cases. American writers state that they are not common in this country. In visiting English hospitals I noticed them to be present in quite a large percentage of the children who had rheumatism, endocarditis or chorea. In my own practice here I have never found them. In my experience, hyperpyrexia is rare in children. The belief that tonsillitis has some relationship to rheumatism seems to me well founded.
All leading authorities agree that the disease is frequently overlooked in young children because of the fugitive character of the joint pains and the mildness of the constitutional symptoms. In my own cases of pericarditis and endocarditis in children. both acute and chronic, aside from those due to the other acute infections, it has been almost always possible to elicit a history of some joint pains at some preceding period.
Pericarditis is less frequent in children, but endocarditis is more frequent than in adults. According to Cheadle, endocarditis occurs in 75 per cent, of the cases of rheumatic fever in children.
The subcutaneous nodules occur almost exclusively in children. Their presence is indicative of a marked tendency to fibrous, and therefore of a severe form of endocarditis. Chorea is also limited to
the period of childhood, or very early adult years. During childhood females are more commonly the subjects of rheumatism than males.
"Another point of distinction between the rheumatism of children and adults is the tendency of the various phases to arise independently of each other. . . . The series of rheumatic events is often spread out or scattered over a term of months or years. Again, the rheumatic series, as seen in children, may be complete or incomplete in any degree" (Albutt's System).
Exudative erythema is more common in children than in adults.
While the occurrence of rheumatism is often overlooked in children because of the mildness of the arthritic symptoms, the opposite mistake of taking other affections for rheumatism is not less frequent. One of these is scurvy. Scurvy occurs almost exclusively within the first two years of life; the pain and tenderness are found in the shafts of the bones rather than at the joints; spongy gums, subcutaneous or mucous membrane hemorrhage, hematuria, etc., aie other differential points.
In the early stage of infantile palsy there is often a hyperesthesia, which leads to a mistaken diagnosis. In this condition the flaccid muscles, with the tenderness being diffuse and general, should prevent mistake. Acute osteomyelitis, tubercular joints, pyemic arthritis, acute osteomyelitis, scarlatinal arthritis, .gonnorrheal arthritis (which may occur in children), the effusions and pains in joints sometimes present in purpura and in hemophilia, are all affections which must sometimes be carefully differentiated. " The acute arthritis of infants" usually seen in sucklings where rheumatism is uncommon, is generally confined to one joint and the effusion rapidly becomes purulent. It is no doubt pyemic. The constitutional symptoms in this disease may be very severe, or they may be slight. Its recognition is important because of the necessity for early evacuation of the joint.
The frequent precedence or coincidence of tonsillitis is possibly an indication that the tonsils are the avenues of entrance for the rheumatic infecti n. As endocarditis may develop with little arthritis, the physician should watch the heart in cases of tonsillitis in children. According to Holt, quinsy is the form of tonsillitis most closely associated with rheumatism.
In childhood heredity is a prominent factor, and a point often of great assistance in making the diagnosis. "The percentage varies from 25 to 60, according to the minuteness of the inquiry and the degree of joint affection which is regarded as sufficiently distinctive of an attack of rheumatism" (N. B. Cheadle,"Cyclopedia of Diseases of Children," v. L, p. 789.
The prognosis in initial attacks is good. There is, however, always the liability to Bulx'quent attacks, with increasing damag,- ID the heart. The occurrence of endocarditis is a calamity to a child. In only rare instances is there restoration ad integrate of an inflamed valve. In a fair proportion of cases the damage is so far repaired that the circulation is efficiently carried on and the individual leads a long and useful life. In many caFes recurring attacks more and more distort the valves; nature's efforts for compensating hypertrophy are overcome by fatty degeneration, of the muscular walls, and dilatation of the cavities, and after a long struggle the patient dies.
The treatment in children should even more than in adults have special reference to the protection of the heart. In this lies the importance of recognizing early the mild cases and their strict confinement to bed. Children with rheumatic antecedents should have special care in protection from chill, exposure and over exertion. Rest is of first importance in the treatment of all cases. The confinement to bed should be enforced until convalescence is fully established. Protection of inflamed joints, support upon splints, the application of ointments containing salicylic acid, oil of wintergreenor ichthyol, are local measures which, by contributing to comfort and rest, also contribute to cure. Personally, I believe that salicylates are of distinct value, but we rarely see the marked effect in children that we often see in adults, because in them arthritis is FO much less marked, and the effects of salicylates are most pronounced upon that phase of rheumatism. Especial care is necessary to protect the stomach from the irritating effects of the drug. Salol and salophen, particularly the latter, are eligible preparations for children; salophen is tasteless, produces no gastric disturbance, and in doses of one grain for each year of the child's
life is efficient. Alkalies should be given in sufficient amounts to keep the urine alkaline in reaction. Water should be given abundantly. Hot sponge baths should be given two to four times in the twentyfour hours. The bowels should be kept open. Upon the occurrence of pericarditis or endocarditis an ice-bag may be applied to the heart, but it must be remembered that young childien sometimes bear cold applications badly. Opiates and all depressing remedies must be avoided or used with great caution. I prefer a strict milk diet during the acute stage if milk is well borne.
The child who has once had an attack should be carefully guarded against subsequent attacks. Those children who show a tendency to repeated attacks should, when possible, spend the winters in a warm and dry climate.

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