Psychothcr. Psychosom. 26: 2-11 (1975)
Cultural Influences on the Incidence and Pattern of Disease J. W. Paulley Ipswich Hospitals, Ipswich, Suffolk
Abstract. Society and its doctors influence disease patterns; examples are taken from two world wars. The high incidence of ulcerative colitis in Jews is seen as cultural rather than racial; differences and changes in the sex incidence of the disease arc discussed in terms of altered male versus female roles. The epidemiological puzzle of multiple sclerosis is examined from the standpoint of a cultural determinant possibly working through a psychosomatically disordered immune response. Hypotheses are advanced for the epidemic of duodenal ulcer and its recent decline accompanied by an increase in coronary disease. Sufferers from both disorders are ‘work-addicts’; society’s new disregard for work and the Puritan ethic may be influential.
Forms of religion and social custom adopted by various cultures and subcul tures seem likely to have been influenced by their archetypal genetic inheritance. Equally, one must ask what would Christianity have been like had not races, adapted to survive the descent of the Northern ice cap laid their chilly hands on it ? What follows is based on a mixture of facts, personal observations and hypotheses. Firstly, doctors themselves influence the pattern of disease.
Conversion Hysteria, Effort Syndrome In the 1939—1945 War in United Kingdom Forces, conversion hysteria was comparatively rare, whereas in the 1914—1918 War it was a common neurosis. The 1939 public recognized conversion hysteria almost as quickly as doctors because of increased literacy and the spread of psychoanalytic concepts via films and books. In contrast, an anxiety state became acceptable, but hysteria has persisted in primitive societies and these nearer the frontier.
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D.A.H. or Da Costa’s syndrome of 1914 1918 became effort syndrome or neurocirculatory asthenia in 1939 and was then seen in epidemic proportions among recruits.
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Some thirteen articles appeared on the subject in The Lancet and British Medical Journal between 1939 and 1942. But by 1943, graduated exercise in rehabilitation camps persuaded soldiers or airmen that they need no longer fear they would die of their symptoms, and the symptoms were no longer ‘rewarded’ by doctors as happened in the first war. By 1939-1945, cardiovascular casualties were approximately '/so of those in the earlier conflict (Metier, 1972).
Ulcerative Colitis - Race or Culture? A personal observation in 1942 that where sthenic, placid individuals with bacillary dysentery recovered in a week on sulphonamides, the asthenic and introspective soldier or airman often continued with post-dysenteric diarrhoea for 1 or 2 months after all pathogens had cleared. This opened my eyes and led to post-war studies on ulcerative colitis, Crohn’s disease and Whipple’s disease. The high incidence of ulcerative colitis among Jews then found in London (Paulley, 1950) (table I) has since been substantiated by Acheson (1960) in US Veterans from three wars in colitis and Crohn’s disease. I concluded (Paulley, 1950, 1956) that this was largely due to cultural influences rather than race and that the tight-knit family circle surrounding the matriarch was one factor in inhibiting emotional independence. There are, no doubt, others. In Suffolk, where there are few Jewish people, strict gentile sects between 1952 and 1963 replaced the Jews at the top of the table of incidence (Paulley, 1963) (table II).
Table I. High incidence of ulcerative colitis among Jews in London replaced by strict religious sects in Suffolk Routine admissions
Middlesex Hospital (1946 1949) Total Jews St. Mark’s Hospital (1946 1949) Total Jews Hast Suffolk and Ipswich Hospital (1953 1962) Total Members of strict sects
Ulcerative colitis
number
%
1,388 160
11.24
92 21
22.8
1,163 97
8.34
39 7
17.9
1,000 77
7.7
126 18
14.2
number
%
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Figures for Middlesex and St. Mark’s Hospitals from Paulley (1950).
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Table //. Religious denominations of 1,000 consecutive routine admissions in Ipswich compared with incidence of some denomination in ulcerative colitis Religious denomination Strict Plymouth Brethern Salvationists Jews Mixed group Less strict Church of England Roman catholics Methodists Congregational
Routine admissions
Ulcerative colitis
9 11 1 7
40 24 16 32
658 63 51 33
728 40 48 40
Extrapolated from ulcerative colitis series as per 1,000 patients.
Other evidence on the influence of cultural differences as opposed to race is afforded by the lower incidence of ulcerative colitis in Eastern as opposed to Western Jews in Israel by Birnbaum et al. (1960). Differences also exist in the sex incidence between British and American colitis series. 15—20 years ago, the femaleimale ratio was 2:1 in UK, as opposed to 1:1 in USA (tables III, IV). Since 1965, the figures in UK for individuals under 35 years are for the first time showing the same 1:1 sex incidence of the Americans (Evans and Acheson, 1965). Could changes in male and female roles, as in the American cult of ‘Mommism’ (Gorer, 1948) and the latest British invention of ‘Unisex’ be the explanation?
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The strict sects seemed to have as tightly knit families as orthodox Jews, but patri archal rather than matriarchal. It has also been found that in ulcerative colitis patients, the extreme aversion to speak their minds lest it lead to verbal retaliation or the risk of the loss of emotional support from a key figure stems from two different family backgrounds. The one rather cosy as met with in strict religious sects ‘with never an angry word’. Such children are also more liable to witness exaggerated displays of parental sensitivity or overt anxiety to bad news, illness and tales of violence. For example, during thunderstorms mirrors may be turned to the wall and metal objects put away. The other background is of quarreling parents with a drunken father coming home to a noisy reception. Early memories of such patients are retreats to the bottom of the bed or to the henhouse to avoid the shouting. Mothers in such circumstances may hinder their childrens’ advance to indepen dence by clinging to them for security. These vulnerable people with colitis may cope for many years with the normal rough and tumble of interpersonal relationships provided a key figure props them up. This accounts for the onset of the disease when the key figure withdraws, takes ill, or dies.
Cultural Influences on the Incidence and Pattern Diseases
5
Table III. Ulcerative colitis. Sex incidence, United States and United Kingdom
United States 1931 1950 (Banks et al.. 1957) 1947-1956 (Lindner et ai. 1960) Before 1950 (Sloan et ai, 1950) United Kindgdom 1939-1948 (Rice et ai, 1960) Before 1950 (Paulley, 1950) 1947-1955 (Cullinan and McDougall, 1957) 1949-1955 (Paulley, 1956) 1950-1967 (Jalan et ai, 1971)
Series
Females Males
Ratio
245 391 2,000
133 183 887
112 208 1,113
1.2:1 0.9:1 0.8:1
129 173
82 118
47 55
1.8:1 2.1:1
346 151 399
212 IOS 226
134 46 173
1.6:1 2.1:1 1.3:1
Table IV. Mortality rate, United Kingdom, per million by age and sex (age group 25 34), from Evans (1971)
1950-1951 1952-1953 1956-1957 1960 1961 1964 1965 1966-1967
Female
Male
Ratio
11.4 12.8 8.2 4.8 4.3 2.8
5.7 7.1 5.1 3.6 3.8 2.9
2:1 1.8:1 1.6:1 1.4:1 1.1:1 1:1
The reason for strange epidemiology of this disorder remains unknown. It could be due to an overriding psychosomatic determinant. Neurologists have long noted inappropriate affect and have attributed this to the disease. Personal studies with the help of close relatives show that this phenomenon long antedates the onset of multiple sclerosis although brain damage may enhance the pre-existing mood as in GPI. It is common for MS patients not to be able to weep (Paulley, 1952). This lack of affect is sometimes so extreme a cover that the opposite ob tains, the euphoria recognized by neurologists. A smiling face, or flat voice, inappropriate to the dire symptoms or events being recounted is a feature of multiple sclerosis - ‘Belle indifférence’. ‘Cry Baby, Cry Baby’ is a form of ridicule prevalent amongst North European children and their descendants. Why is man the only primate to weep
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Multiple Sclerosis
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6
for emotional reasons, and why do tears contain 1,000 times the concentration of lysozyme of all other secretions? Is this only a bacterial defence? If so why so copious during emotion? Tennyson wrote: 'Home they brought her warrior dead, She nor swooned nor utter’d cry: All her maidens watching said, “She must weep, or she will die...” ’ (The Princess, vi, introductory song)
As in ulcerative colitis and Crohn’s disease, personal studies on multiple sclerosis suggest that it occurs in families and subcultures and cultures favouring abnormally prolonged emotional dependence of children into adulthood, coupled with their failure to learn to express certain emotions especially aggres sion because their parents do not, or cannot; or because of a frank embargo on such expression. The high incidence of multiple sclerosis in social classes 1 and II was reported by Miller et al. (1960). Russell (1971) confirmed this (table V) and implicated an environmental factor. Usual environmental scapegoats are diet, smoking, alcohol or infection. But culturally determined emotional inhibition has yet to be considered. For emigrants from Northern Europe, the highest incidence occurs where cultural mores and climate approximate to Europe, i.e. the New England States of the USA. Currently, latent virus infection is the fashionable theory, yet the ‘slow virus’ of a pattern of emotional repression acquired in childhood perhaps acting through a degree of immunological incompetence to an infective agent {Solomon and Amkraut, 1972) needs to be excluded. The incidence gradient of MS falls North to South across the USA and Table V. Employed males: early and late onset of MS and social class compared with social-class distribution in regional and national samples; from Russell (1971)
20-29 years of age MS patients Regional sample, National sample, 30-54 years of age MS patients Regional sample, National sample,
Social class
I and II, %
III—V, %
33.3 11.8 13.9
66.7
1951 census 1966 census
1951 census 1966 census
59.6 22.1 21.0
40.4 77.9 79.0
88.2
86.1
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Sample
7
Cultural Influences on the Incidence and Pattern Diseases
from Northern Europe to the Mediterranean. There is a similar local gradient in Switzerland. In Scotland the Celts have a lower incidence than Scots of Norse or Anglo-Saxon stock {Sutherland, 1956) and Celtic Wales has a lower rate of general practitioner consultations for multiple sclerosis than East Anglia {Logan and Cushion, 1958) (fig. 1). In Israel, Alter et al. (1960) found a prevalence for native Israelis 4/100,000 and 7/100,000 for immigrants from Middle-East and North Africa, but 32/100,000 for European immigrants.
-- “ J
7?
— Jr
A
JO
I »
êm« 4 1
h'ig. 1. Diagrammatic representation of differences of emotional response in Celtic Wales and Anglo-Saxon/Norse East Anglia.
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-•] i «
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Also supporting cultural influences is the age/sex incidence which falls earlier as ulcer ative colitis, on females than males. This could be related to the higher risk for women during the reproductive period of life (McAlpine et at, 1972), and would fit with Inman's (1948) and my own observations, on the frequent combination of birth fantasies and immaturity in the psychogenesis of the disorder, with a temporal relationship of hours or days of onset and relapse to the crises of courtship, marriage and birth. By virtue of sexual fantasies and guilt, their sisters’ or friends’ babies can be as provocative as their own. Aggression or its sublimation in achievement or social success tends to be more in hibited in long settled communities with rigid hierarchies, defensive taboos, than in colonies, or new countries with a frontier spirit and greater freedom of opportunity. Yet in New England scarcely had emigrants fled the harshest religious intolerance than they fashioned their own, e.g. the witches of Salem. Death For 50 years death has been brushed under the carpet in the West as if it did not exist. Ritualized mourning seems to have had a most valuable function, and still has in some cultures and subcultures, but Jews are now abandoning orthodoxy for the doubtful advan tage of Anglo-Saxon mores. Prolonged mourning for the loss of a love-object by death or otherwise is a recurrent feature of personal longitudinal studies of the auto-immune dis orders such as rheumatoid arthritis and SLE. Love Love, approval, or emotional warmth in puritanic The children of reserved parents, or parent substitutes, this facility or expression as if they were born without children may in turn be similarly affected by their emotional spontaneity.
cultures is often heavily inhibited. may be as crippled for the lack of an arm or leg, and then their own failure to learn the technique of
Duodenal Ulcer and Coronary Disease
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Such a background has impressed the author in longitudinal studies of duodenal ulcer sufferers who strive by work throughout their lives to obtain the love and approval they found so hard to win in their childhood, and statistics (fig. 2) collected 25 years ago show the influence of early parental death in a restricted subgroup of duodenal ulcer sufferers born of others lost in the carnage of the 1914—1918 War compared with ulcerative colitis gastric ulcer and controls. Between 1900 and 1950, there arose an epidemic of duodenal ulcer in Western societies. Its recent decline in the South of England and its replacement by a comparable epidemic of coronary disease is a contemporary phenomenon requiring explanation. The following hypothesis is presented: before 1900, the incidence of duode nal ulcer was low (Christian, 1929; Cushing, 1932; Rokitansky, 1841). If Mirsky’s (1958) ‘oral tension’ is even partly genetically determined, then some
Cultural Influences on the Incidence and Pattern Diseases
9
Percent 0
5
10
15
20
0
5
10
15
25 Duodenal ulcer (20/70)
Colitis (18/149)
Colitis (23/149)
Gastric ulcer (9/62)
Gastric ulcer (13/62)
Controls (48/480) Early maternal death
20
Duodenal ulcer (16/70)
Controls (83/480) Early paternal death
Fig. 2. Rate of early parental death in patients at Middlesex Hospital in the period 1947-1948 with duodenal ulcer, colitis, gastric ulcer and a series of controls. Early parental death being death of parent before child reached 15 years. (The controls were from the following sources: 99 casualty cases; 177 eye clinic cases; 204 radiotherapy patients.) infants born with a high degree of it will be hard to satisfy both in terms of food or love. It has been suggested that food and love are substituted for each other at a marginally conscious cerebral level, whereas in duodenal ulcer, the confusion would appear to be at the psycho-physiological level of inappropriately high gastric secretion in lieu of ungratified demands for love and esteem. The hypervascular and hypersecreting stomach can be regarded as physiologically perma nently prepared for a meal.
This new situation coincided with tough late-Victorian attitudes on child rearing, themselves partly a response to overcrowding. Emotional warmth was frowned upon and restrained approval for many children was reserved for perfor mance, first at home, then at school and later at work. The ‘rat race’ was on. From 1920 to 1939, the Western World saw the tragedy of mass unemployment, and parents of that time could hardly be blamed for holding the threat of it before their children from an early age, indeed, despair was often in their faces. Under such circumstances, the child born with high ‘oral tension’ surviving in large numbers for the first time in history, would have found assuagement of his hunger for love, esteem and approval, — an uphill job, and only gained by exceptional diligence. And if the domestic emotional climate of approval hap pened to be chilly too, he had to redouble his efforts to obtain some measure of reward at work, or in his community. Yet any hypothesis for the rise in incidence of duodenal ulcer has also to
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Over 100 years ago, a high proportion of children with unmet high ‘oral tension’ would probably have died in infancy from intercurrent infections, or from nutritional or emotional starvation just as deprived children still die today in institutional nurseries. But during the last 20 years of the 19th century with improved sanitation, larger families were not only born, but also survived only to face increasing competition in the family, and later in the labour market.
Paulley
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explain its recession in the South of the United Kingdom since 1950, and also a similar but lesser and slower fall in the North of the country (Susser and Stein, 1962; Pulvertaft, 1968). Two possible reasons present, firstly high though these infants’ needs may be, they have been met initially, if at some cost, by a generation of mothers who struggled with the guilt induced by popular interpretations of Freudian teach ings, and from childhood onwards, by the udder of the Welfare State, introduced significantly in 1945 when duodenal ulcer began to decline. Secondly, there are indications that the UK, the first country to espouse the work ethic of the Industrial Revolution, may prove to be the first country to reject it. Differences in Scotland and the North can be explained by higher unemployment there and attempts to hold on to Calvinistic values, whereas in the South, paternalism and authority are in full retreat. Today instead of about one third of general medical patients in hospitals in the South of England being patients with peptic ulcer as between 1930 and 1939, approximately one third now have cardiac infarction. Watkinson (1956, 1958) found the incidence of coronary disease in duodenal ulcer patients significantly beyond normal expectation. Common smoking habits, and milk diets were then suspected. But do they not also share similar attitudes of ‘work addiction’? Therefore, could it be that in the old society, the rewards for work were considerable, if at the price of an ulcer, but today with work and money ridiculed in Britain at least, and the coronary patient’s work ethic rejected by the new managers, by his workmates, his wife and his children, his masculinity is threatened, and with it life itself? This fits the conclusions of a number of studies on coronary disease (Van der Valk and Groen, 1967; Pelser, 1967; Hinkle, 1968; Cassem and Rackett, 1971; Appels, 1973).
References
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Acheson, E.C.: Distribution of ulcerative colitis and regional enteritis in United States veterans with particular reference to Jewish religion. Gut I: 291 93 (1960). Alter, M A l l i s o n , M.S.; Talbert, G.R., and Kurland, L.T.: Geographic distribution of multiple sclerosis. Wld Neurol. I: 55 (1960). Appels, A.: Coronary heart disease as a cultural disease. Psychother. Psychosom. 22: 320-324 (1973). Banks, BE.: Korelitz, B.I., and Zetzel, /... The course of non-specific ulcerative colitis. Review of twenty years experience. Gastroenterology 32: 983 1912 (1957). Birnbaum, D.: Groen, J.J., and Kallner, G.: Ulcerative colitis among the ethnic groups in Israel. Arch, intern. Med. 105: 843-848 (1960). Cassem, N.E. and Hackett, T.P.: Psychiatric consultant in a coronary care unit. Ann. intern. Med. 75: 9 14 (1971). Christian, H.A.: 16th Annual Report of Peter Bent Brigham Hospital, p. 139 (1929). Cullinan, E.R. and McDougall, I.P.: Natural history of ulcerative colitis. Lancet i: 487-489 (1957). Cushing, H.: Peptic ulcers and the interbrain. Surg. Gynec. Obstet. 55: 1 34 (1932).
Cultural Influences on the Incidence and Pattern Diseases
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J. W. Paulley, MD, Ipswich Hospitals, Ipswich, Suffolk (UK)
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Evans, J.G.: Trends in mortality from ulcerative colitis in England and Wales. Gut 12: 119 122 (1971). Gorer, G.E.S.: The Americans (Cresset Press, London 1948). Hinkle, L.E.: Occupation, education and coronary disease. Science 161: 238 246 (1968). Inman, ICS..' Can emotional conflict induce disseminated sclerosis? Brit. J. Psychol. 21: 135 154 (1948). Jalan, K.N.; Prestcott, M.H.J.; Sircus, W.: Card, W.L.: McManus, J.P.A.: Falconer, C.W.A.: Small, W.P.; Smith, A.M., and Bruce, J.: Ulcerative colitis; a clinical study of 399 patients. J. roy. Coll. Surg., Edin. 16: 338 351 (1971). Lindner, A.E.: King, R.C., and Bolt, R.J.: Chronic ulcerative colitis. Gastroenterology 39: 153-160 (1960). Logan, W.P.D. and Cushion, A.A.: General Registrar Office. Studies on medical and popula tion subjects, No. 14 (1958). McAlpine D.: Lumsden, C.E., and Acheson E.G.: Multiple sclerosis. A re-appraisal (Churchill Livingstone, Edinburgh 1972). Metier, W.F.: History of the second world war casualties and statistics, p. 59 (HMSO, London 1972). Mirsky, I.A.: Physiology, psychologic and social determinants in the aetiology of duodenal ulcer. Amer. J. digest. Dis. 3: 285 314 (1958). Miller, 11., Ridley A., and Schopira, K.: Multiple sclerosis, a note on social incidence. Brit, mod. J.«V 343 345 (1960). Paulley, J. W.: Ulcerative colitis; 173 cases. Gastroenterology 16: 566 (1950). Paulley, J.W.: Disseminated sclerosis. Lancet i: 1305 (1952). Paulley, J. W.: Psychotherapy in ulcerative colitis. Lancet ii: 215- 218 (1956). Paulley, J.W.: Ulcerative colitis. Brit. med. 1. ii: 308 (1963). Paulley, J.W.: Medical management of ulcerative colitis. Proc. roy. Soc. Med. 64: 971 973 (1971). Paulley, J. W.: Psychosomatic and other aspects of ulcerative colitis in the aged. Mod. Geriat. 2: 30-34 (1972). Pelser, H.E.: Psychological aspects of the treatment of patients with coronary infarction. J. psychosom. Res. 11: 47 - 49 (1967). Pulvertaft, C.N.: Comments on the incidence and natural history of gastric and duodenal ulcer. Postgrad, med. J. 44: 597 602 (1968). Rice, Oxley J.W. and Truelove, S.: Ulcerative colitis. Course and prognosis. Lancet i: 663-666 (1950). Rokitansky, C.: Cited by Cushing (1932). Russell, W.R.:Multiple sclerosis: occupation and social group atonset. Lancet ii: 832-834 (1971). Sloan, W.B.; Bargen, J.A., and Cage, R.P.: Life histories of patients with chronic ulcerative colitis; review of 2,000 cases. Gastroenterology 16: 25-38 (1950). Solomon, G.F. and Amkraut, A.A.: Erontiers of radiation therapy and oncology, vol. 7, pp. 88 96 (1972). Susser, M. and Stein, A.: Civilisation and peptic ulcer. Lancet i: 115 119 (1962). Sutherland, J.M.: Observations on the prevalence of multiple sclerosis in Northern Scotland. Brain 79: 635 654 (1956). Van der Valk, J.M. and Groen, J.J.: Personality structure and conflict situation in patients with myocardial infarction. J. psychosom. Res. 11: 41 46 (1967). Watkinson, F.: Relation of chronic peptic ulcer to coronary sclerosis. Gastroenterogia 85: 201 204 (1956); 89: 292 301 (1958).
Cultural Influences on the Incidence and Pattern of Disease J. W. Paulley Ipswich Hospitals, Ipswich, Suffolk
Abstract. Society and its doctors influence disease patterns; examples are taken from two world wars. The high incidence of ulcerative colitis in Jews is seen as cultural rather than racial; differences and changes in the sex incidence of the disease arc discussed in terms of altered male versus female roles. The epidemiological puzzle of multiple sclerosis is examined from the standpoint of a cultural determinant possibly working through a psychosomatically disordered immune response. Hypotheses are advanced for the epidemic of duodenal ulcer and its recent decline accompanied by an increase in coronary disease. Sufferers from both disorders are ‘work-addicts’; society’s new disregard for work and the Puritan ethic may be influential.
Forms of religion and social custom adopted by various cultures and subcul tures seem likely to have been influenced by their archetypal genetic inheritance. Equally, one must ask what would Christianity have been like had not races, adapted to survive the descent of the Northern ice cap laid their chilly hands on it ? What follows is based on a mixture of facts, personal observations and hypotheses. Firstly, doctors themselves influence the pattern of disease.
Conversion Hysteria, Effort Syndrome In the 1939—1945 War in United Kingdom Forces, conversion hysteria was comparatively rare, whereas in the 1914—1918 War it was a common neurosis. The 1939 public recognized conversion hysteria almost as quickly as doctors because of increased literacy and the spread of psychoanalytic concepts via films and books. In contrast, an anxiety state became acceptable, but hysteria has persisted in primitive societies and these nearer the frontier.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 11:26:45 PM
D.A.H. or Da Costa’s syndrome of 1914 1918 became effort syndrome or neurocirculatory asthenia in 1939 and was then seen in epidemic proportions among recruits.
Paulley
3
Some thirteen articles appeared on the subject in The Lancet and British Medical Journal between 1939 and 1942. But by 1943, graduated exercise in rehabilitation camps persuaded soldiers or airmen that they need no longer fear they would die of their symptoms, and the symptoms were no longer ‘rewarded’ by doctors as happened in the first war. By 1939-1945, cardiovascular casualties were approximately '/so of those in the earlier conflict (Metier, 1972).
Ulcerative Colitis - Race or Culture? A personal observation in 1942 that where sthenic, placid individuals with bacillary dysentery recovered in a week on sulphonamides, the asthenic and introspective soldier or airman often continued with post-dysenteric diarrhoea for 1 or 2 months after all pathogens had cleared. This opened my eyes and led to post-war studies on ulcerative colitis, Crohn’s disease and Whipple’s disease. The high incidence of ulcerative colitis among Jews then found in London (Paulley, 1950) (table I) has since been substantiated by Acheson (1960) in US Veterans from three wars in colitis and Crohn’s disease. I concluded (Paulley, 1950, 1956) that this was largely due to cultural influences rather than race and that the tight-knit family circle surrounding the matriarch was one factor in inhibiting emotional independence. There are, no doubt, others. In Suffolk, where there are few Jewish people, strict gentile sects between 1952 and 1963 replaced the Jews at the top of the table of incidence (Paulley, 1963) (table II).
Table I. High incidence of ulcerative colitis among Jews in London replaced by strict religious sects in Suffolk Routine admissions
Middlesex Hospital (1946 1949) Total Jews St. Mark’s Hospital (1946 1949) Total Jews Hast Suffolk and Ipswich Hospital (1953 1962) Total Members of strict sects
Ulcerative colitis
number
%
1,388 160
11.24
92 21
22.8
1,163 97
8.34
39 7
17.9
1,000 77
7.7
126 18
14.2
number
%
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Figures for Middlesex and St. Mark’s Hospitals from Paulley (1950).
Paulley
4
Table //. Religious denominations of 1,000 consecutive routine admissions in Ipswich compared with incidence of some denomination in ulcerative colitis Religious denomination Strict Plymouth Brethern Salvationists Jews Mixed group Less strict Church of England Roman catholics Methodists Congregational
Routine admissions
Ulcerative colitis
9 11 1 7
40 24 16 32
658 63 51 33
728 40 48 40
Extrapolated from ulcerative colitis series as per 1,000 patients.
Other evidence on the influence of cultural differences as opposed to race is afforded by the lower incidence of ulcerative colitis in Eastern as opposed to Western Jews in Israel by Birnbaum et al. (1960). Differences also exist in the sex incidence between British and American colitis series. 15—20 years ago, the femaleimale ratio was 2:1 in UK, as opposed to 1:1 in USA (tables III, IV). Since 1965, the figures in UK for individuals under 35 years are for the first time showing the same 1:1 sex incidence of the Americans (Evans and Acheson, 1965). Could changes in male and female roles, as in the American cult of ‘Mommism’ (Gorer, 1948) and the latest British invention of ‘Unisex’ be the explanation?
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 11:26:45 PM
The strict sects seemed to have as tightly knit families as orthodox Jews, but patri archal rather than matriarchal. It has also been found that in ulcerative colitis patients, the extreme aversion to speak their minds lest it lead to verbal retaliation or the risk of the loss of emotional support from a key figure stems from two different family backgrounds. The one rather cosy as met with in strict religious sects ‘with never an angry word’. Such children are also more liable to witness exaggerated displays of parental sensitivity or overt anxiety to bad news, illness and tales of violence. For example, during thunderstorms mirrors may be turned to the wall and metal objects put away. The other background is of quarreling parents with a drunken father coming home to a noisy reception. Early memories of such patients are retreats to the bottom of the bed or to the henhouse to avoid the shouting. Mothers in such circumstances may hinder their childrens’ advance to indepen dence by clinging to them for security. These vulnerable people with colitis may cope for many years with the normal rough and tumble of interpersonal relationships provided a key figure props them up. This accounts for the onset of the disease when the key figure withdraws, takes ill, or dies.
Cultural Influences on the Incidence and Pattern Diseases
5
Table III. Ulcerative colitis. Sex incidence, United States and United Kingdom
United States 1931 1950 (Banks et al.. 1957) 1947-1956 (Lindner et ai. 1960) Before 1950 (Sloan et ai, 1950) United Kindgdom 1939-1948 (Rice et ai, 1960) Before 1950 (Paulley, 1950) 1947-1955 (Cullinan and McDougall, 1957) 1949-1955 (Paulley, 1956) 1950-1967 (Jalan et ai, 1971)
Series
Females Males
Ratio
245 391 2,000
133 183 887
112 208 1,113
1.2:1 0.9:1 0.8:1
129 173
82 118
47 55
1.8:1 2.1:1
346 151 399
212 IOS 226
134 46 173
1.6:1 2.1:1 1.3:1
Table IV. Mortality rate, United Kingdom, per million by age and sex (age group 25 34), from Evans (1971)
1950-1951 1952-1953 1956-1957 1960 1961 1964 1965 1966-1967
Female
Male
Ratio
11.4 12.8 8.2 4.8 4.3 2.8
5.7 7.1 5.1 3.6 3.8 2.9
2:1 1.8:1 1.6:1 1.4:1 1.1:1 1:1
The reason for strange epidemiology of this disorder remains unknown. It could be due to an overriding psychosomatic determinant. Neurologists have long noted inappropriate affect and have attributed this to the disease. Personal studies with the help of close relatives show that this phenomenon long antedates the onset of multiple sclerosis although brain damage may enhance the pre-existing mood as in GPI. It is common for MS patients not to be able to weep (Paulley, 1952). This lack of affect is sometimes so extreme a cover that the opposite ob tains, the euphoria recognized by neurologists. A smiling face, or flat voice, inappropriate to the dire symptoms or events being recounted is a feature of multiple sclerosis - ‘Belle indifférence’. ‘Cry Baby, Cry Baby’ is a form of ridicule prevalent amongst North European children and their descendants. Why is man the only primate to weep
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Multiple Sclerosis
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for emotional reasons, and why do tears contain 1,000 times the concentration of lysozyme of all other secretions? Is this only a bacterial defence? If so why so copious during emotion? Tennyson wrote: 'Home they brought her warrior dead, She nor swooned nor utter’d cry: All her maidens watching said, “She must weep, or she will die...” ’ (The Princess, vi, introductory song)
As in ulcerative colitis and Crohn’s disease, personal studies on multiple sclerosis suggest that it occurs in families and subcultures and cultures favouring abnormally prolonged emotional dependence of children into adulthood, coupled with their failure to learn to express certain emotions especially aggres sion because their parents do not, or cannot; or because of a frank embargo on such expression. The high incidence of multiple sclerosis in social classes 1 and II was reported by Miller et al. (1960). Russell (1971) confirmed this (table V) and implicated an environmental factor. Usual environmental scapegoats are diet, smoking, alcohol or infection. But culturally determined emotional inhibition has yet to be considered. For emigrants from Northern Europe, the highest incidence occurs where cultural mores and climate approximate to Europe, i.e. the New England States of the USA. Currently, latent virus infection is the fashionable theory, yet the ‘slow virus’ of a pattern of emotional repression acquired in childhood perhaps acting through a degree of immunological incompetence to an infective agent {Solomon and Amkraut, 1972) needs to be excluded. The incidence gradient of MS falls North to South across the USA and Table V. Employed males: early and late onset of MS and social class compared with social-class distribution in regional and national samples; from Russell (1971)
20-29 years of age MS patients Regional sample, National sample, 30-54 years of age MS patients Regional sample, National sample,
Social class
I and II, %
III—V, %
33.3 11.8 13.9
66.7
1951 census 1966 census
1951 census 1966 census
59.6 22.1 21.0
40.4 77.9 79.0
88.2
86.1
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Sample
7
Cultural Influences on the Incidence and Pattern Diseases
from Northern Europe to the Mediterranean. There is a similar local gradient in Switzerland. In Scotland the Celts have a lower incidence than Scots of Norse or Anglo-Saxon stock {Sutherland, 1956) and Celtic Wales has a lower rate of general practitioner consultations for multiple sclerosis than East Anglia {Logan and Cushion, 1958) (fig. 1). In Israel, Alter et al. (1960) found a prevalence for native Israelis 4/100,000 and 7/100,000 for immigrants from Middle-East and North Africa, but 32/100,000 for European immigrants.
-- “ J
7?
— Jr
A
JO
I »
êm« 4 1
h'ig. 1. Diagrammatic representation of differences of emotional response in Celtic Wales and Anglo-Saxon/Norse East Anglia.
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-•] i «
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Also supporting cultural influences is the age/sex incidence which falls earlier as ulcer ative colitis, on females than males. This could be related to the higher risk for women during the reproductive period of life (McAlpine et at, 1972), and would fit with Inman's (1948) and my own observations, on the frequent combination of birth fantasies and immaturity in the psychogenesis of the disorder, with a temporal relationship of hours or days of onset and relapse to the crises of courtship, marriage and birth. By virtue of sexual fantasies and guilt, their sisters’ or friends’ babies can be as provocative as their own. Aggression or its sublimation in achievement or social success tends to be more in hibited in long settled communities with rigid hierarchies, defensive taboos, than in colonies, or new countries with a frontier spirit and greater freedom of opportunity. Yet in New England scarcely had emigrants fled the harshest religious intolerance than they fashioned their own, e.g. the witches of Salem. Death For 50 years death has been brushed under the carpet in the West as if it did not exist. Ritualized mourning seems to have had a most valuable function, and still has in some cultures and subcultures, but Jews are now abandoning orthodoxy for the doubtful advan tage of Anglo-Saxon mores. Prolonged mourning for the loss of a love-object by death or otherwise is a recurrent feature of personal longitudinal studies of the auto-immune dis orders such as rheumatoid arthritis and SLE. Love Love, approval, or emotional warmth in puritanic The children of reserved parents, or parent substitutes, this facility or expression as if they were born without children may in turn be similarly affected by their emotional spontaneity.
cultures is often heavily inhibited. may be as crippled for the lack of an arm or leg, and then their own failure to learn the technique of
Duodenal Ulcer and Coronary Disease
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Such a background has impressed the author in longitudinal studies of duodenal ulcer sufferers who strive by work throughout their lives to obtain the love and approval they found so hard to win in their childhood, and statistics (fig. 2) collected 25 years ago show the influence of early parental death in a restricted subgroup of duodenal ulcer sufferers born of others lost in the carnage of the 1914—1918 War compared with ulcerative colitis gastric ulcer and controls. Between 1900 and 1950, there arose an epidemic of duodenal ulcer in Western societies. Its recent decline in the South of England and its replacement by a comparable epidemic of coronary disease is a contemporary phenomenon requiring explanation. The following hypothesis is presented: before 1900, the incidence of duode nal ulcer was low (Christian, 1929; Cushing, 1932; Rokitansky, 1841). If Mirsky’s (1958) ‘oral tension’ is even partly genetically determined, then some
Cultural Influences on the Incidence and Pattern Diseases
9
Percent 0
5
10
15
20
0
5
10
15
25 Duodenal ulcer (20/70)
Colitis (18/149)
Colitis (23/149)
Gastric ulcer (9/62)
Gastric ulcer (13/62)
Controls (48/480) Early maternal death
20
Duodenal ulcer (16/70)
Controls (83/480) Early paternal death
Fig. 2. Rate of early parental death in patients at Middlesex Hospital in the period 1947-1948 with duodenal ulcer, colitis, gastric ulcer and a series of controls. Early parental death being death of parent before child reached 15 years. (The controls were from the following sources: 99 casualty cases; 177 eye clinic cases; 204 radiotherapy patients.) infants born with a high degree of it will be hard to satisfy both in terms of food or love. It has been suggested that food and love are substituted for each other at a marginally conscious cerebral level, whereas in duodenal ulcer, the confusion would appear to be at the psycho-physiological level of inappropriately high gastric secretion in lieu of ungratified demands for love and esteem. The hypervascular and hypersecreting stomach can be regarded as physiologically perma nently prepared for a meal.
This new situation coincided with tough late-Victorian attitudes on child rearing, themselves partly a response to overcrowding. Emotional warmth was frowned upon and restrained approval for many children was reserved for perfor mance, first at home, then at school and later at work. The ‘rat race’ was on. From 1920 to 1939, the Western World saw the tragedy of mass unemployment, and parents of that time could hardly be blamed for holding the threat of it before their children from an early age, indeed, despair was often in their faces. Under such circumstances, the child born with high ‘oral tension’ surviving in large numbers for the first time in history, would have found assuagement of his hunger for love, esteem and approval, — an uphill job, and only gained by exceptional diligence. And if the domestic emotional climate of approval hap pened to be chilly too, he had to redouble his efforts to obtain some measure of reward at work, or in his community. Yet any hypothesis for the rise in incidence of duodenal ulcer has also to
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Over 100 years ago, a high proportion of children with unmet high ‘oral tension’ would probably have died in infancy from intercurrent infections, or from nutritional or emotional starvation just as deprived children still die today in institutional nurseries. But during the last 20 years of the 19th century with improved sanitation, larger families were not only born, but also survived only to face increasing competition in the family, and later in the labour market.
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explain its recession in the South of the United Kingdom since 1950, and also a similar but lesser and slower fall in the North of the country (Susser and Stein, 1962; Pulvertaft, 1968). Two possible reasons present, firstly high though these infants’ needs may be, they have been met initially, if at some cost, by a generation of mothers who struggled with the guilt induced by popular interpretations of Freudian teach ings, and from childhood onwards, by the udder of the Welfare State, introduced significantly in 1945 when duodenal ulcer began to decline. Secondly, there are indications that the UK, the first country to espouse the work ethic of the Industrial Revolution, may prove to be the first country to reject it. Differences in Scotland and the North can be explained by higher unemployment there and attempts to hold on to Calvinistic values, whereas in the South, paternalism and authority are in full retreat. Today instead of about one third of general medical patients in hospitals in the South of England being patients with peptic ulcer as between 1930 and 1939, approximately one third now have cardiac infarction. Watkinson (1956, 1958) found the incidence of coronary disease in duodenal ulcer patients significantly beyond normal expectation. Common smoking habits, and milk diets were then suspected. But do they not also share similar attitudes of ‘work addiction’? Therefore, could it be that in the old society, the rewards for work were considerable, if at the price of an ulcer, but today with work and money ridiculed in Britain at least, and the coronary patient’s work ethic rejected by the new managers, by his workmates, his wife and his children, his masculinity is threatened, and with it life itself? This fits the conclusions of a number of studies on coronary disease (Van der Valk and Groen, 1967; Pelser, 1967; Hinkle, 1968; Cassem and Rackett, 1971; Appels, 1973).
References
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Acheson, E.C.: Distribution of ulcerative colitis and regional enteritis in United States veterans with particular reference to Jewish religion. Gut I: 291 93 (1960). Alter, M A l l i s o n , M.S.; Talbert, G.R., and Kurland, L.T.: Geographic distribution of multiple sclerosis. Wld Neurol. I: 55 (1960). Appels, A.: Coronary heart disease as a cultural disease. Psychother. Psychosom. 22: 320-324 (1973). Banks, BE.: Korelitz, B.I., and Zetzel, /... The course of non-specific ulcerative colitis. Review of twenty years experience. Gastroenterology 32: 983 1912 (1957). Birnbaum, D.: Groen, J.J., and Kallner, G.: Ulcerative colitis among the ethnic groups in Israel. Arch, intern. Med. 105: 843-848 (1960). Cassem, N.E. and Hackett, T.P.: Psychiatric consultant in a coronary care unit. Ann. intern. Med. 75: 9 14 (1971). Christian, H.A.: 16th Annual Report of Peter Bent Brigham Hospital, p. 139 (1929). Cullinan, E.R. and McDougall, I.P.: Natural history of ulcerative colitis. Lancet i: 487-489 (1957). Cushing, H.: Peptic ulcers and the interbrain. Surg. Gynec. Obstet. 55: 1 34 (1932).
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J. W. Paulley, MD, Ipswich Hospitals, Ipswich, Suffolk (UK)
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Evans, J.G.: Trends in mortality from ulcerative colitis in England and Wales. Gut 12: 119 122 (1971). Gorer, G.E.S.: The Americans (Cresset Press, London 1948). Hinkle, L.E.: Occupation, education and coronary disease. Science 161: 238 246 (1968). Inman, ICS..' Can emotional conflict induce disseminated sclerosis? Brit. J. Psychol. 21: 135 154 (1948). Jalan, K.N.; Prestcott, M.H.J.; Sircus, W.: Card, W.L.: McManus, J.P.A.: Falconer, C.W.A.: Small, W.P.; Smith, A.M., and Bruce, J.: Ulcerative colitis; a clinical study of 399 patients. J. roy. Coll. Surg., Edin. 16: 338 351 (1971). Lindner, A.E.: King, R.C., and Bolt, R.J.: Chronic ulcerative colitis. Gastroenterology 39: 153-160 (1960). Logan, W.P.D. and Cushion, A.A.: General Registrar Office. Studies on medical and popula tion subjects, No. 14 (1958). McAlpine D.: Lumsden, C.E., and Acheson E.G.: Multiple sclerosis. A re-appraisal (Churchill Livingstone, Edinburgh 1972). Metier, W.F.: History of the second world war casualties and statistics, p. 59 (HMSO, London 1972). Mirsky, I.A.: Physiology, psychologic and social determinants in the aetiology of duodenal ulcer. Amer. J. digest. Dis. 3: 285 314 (1958). Miller, 11., Ridley A., and Schopira, K.: Multiple sclerosis, a note on social incidence. Brit, mod. J.«V 343 345 (1960). Paulley, J. W.: Ulcerative colitis; 173 cases. Gastroenterology 16: 566 (1950). Paulley, J.W.: Disseminated sclerosis. Lancet i: 1305 (1952). Paulley, J. W.: Psychotherapy in ulcerative colitis. Lancet ii: 215- 218 (1956). Paulley, J.W.: Ulcerative colitis. Brit. med. 1. ii: 308 (1963). Paulley, J.W.: Medical management of ulcerative colitis. Proc. roy. Soc. Med. 64: 971 973 (1971). Paulley, J. W.: Psychosomatic and other aspects of ulcerative colitis in the aged. Mod. Geriat. 2: 30-34 (1972). Pelser, H.E.: Psychological aspects of the treatment of patients with coronary infarction. J. psychosom. Res. 11: 47 - 49 (1967). Pulvertaft, C.N.: Comments on the incidence and natural history of gastric and duodenal ulcer. Postgrad, med. J. 44: 597 602 (1968). Rice, Oxley J.W. and Truelove, S.: Ulcerative colitis. Course and prognosis. Lancet i: 663-666 (1950). Rokitansky, C.: Cited by Cushing (1932). Russell, W.R.:Multiple sclerosis: occupation and social group atonset. Lancet ii: 832-834 (1971). Sloan, W.B.; Bargen, J.A., and Cage, R.P.: Life histories of patients with chronic ulcerative colitis; review of 2,000 cases. Gastroenterology 16: 25-38 (1950). Solomon, G.F. and Amkraut, A.A.: Erontiers of radiation therapy and oncology, vol. 7, pp. 88 96 (1972). Susser, M. and Stein, A.: Civilisation and peptic ulcer. Lancet i: 115 119 (1962). Sutherland, J.M.: Observations on the prevalence of multiple sclerosis in Northern Scotland. Brain 79: 635 654 (1956). Van der Valk, J.M. and Groen, J.J.: Personality structure and conflict situation in patients with myocardial infarction. J. psychosom. Res. 11: 41 46 (1967). Watkinson, F.: Relation of chronic peptic ulcer to coronary sclerosis. Gastroenterogia 85: 201 204 (1956); 89: 292 301 (1958).
