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Chapter VIII

Contents

CHAPTER VIII

Rheumatic Fever

Lowell A. Rantz, M.D.

Rheumatic fever has been a problem to the U.S. Army in all of its wars for which historical data are available, although it attracted little attention before World War II. Enteric infection and malaria in earlier wars, and influenza and its complications in World War I, overshadowed all other acute diseases. Inadequate diagnosis also prevented the recognition of the military importance of this disorder.

The recorded experience of the U.S. Army in the American Civil War1 reveals that acute rheumatism occurred with remarkable frequency. In 5.2 years, 146,000 cases were reported among white troops at a rate of 61 per 1,000 per annum. Certainly, not all of these were acute rheumatic fever, but examination of the case records that have been preserved in the history of that war indicates that a substantial number of them was certainly this disease. This impression is confirmed by 642 deaths caused by rheumatism, endocarditis, and pericarditis. Furthermore, the disease occurred principally in the winter among fresh levies of troops, an epidemiological pattern which resembles that of rheumatic fever during World War II. In retrospect, it is impossible to define the magnitude of the problem of rheumatic fever in the Civil War, but it must have been great.

The situation during World War I was similar.2 There were 24,770 admissions for acute articular rheumatism reported, but the significance of this disease was apparently overlooked even though it was occurring at the rate of 6.00 per 1,000 per annum. The fact that many of these cases were rheumatic fever was not appreciated, and this disease is not mentioned by name in the official history of the Medical Department in World War I. The disease occurred with greatest frequency in the same areas as it did during World War II but at substantially higher rates.

In spite of this background and of the great advances that had been made in the period between the wars in knowledge of the pathogenesis and natural history of the disease, the U.S. Army Medical Department was poorly equipped to cope with the problem of rheumatic fever in the first years of World War II. This was largely the result of several well-defined factors. The first, and most important, was the failure of the Medical Department to realize the importance of rheumatic fever as a military problem. Rheumatic

1Medical and Surgical History of the War of the Rebellion. Medical History. Washington: Government Printing Office, 1870, pt. I, vol. 1, pp. 637-639.
2The Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1925, vol. XV, pt. 2, p. 86.


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fever was not required to be reported by all facilities on the weekly statistical summary until December 19413 and was often incorrectly diagnosed during the following 2 years.

Of equal importance was the failure to appreciate the intimate relationship between infection by group A hemolytic streptococci and rheumatic fever. Medical officers in the field were not trained to distinguish streptococcal from nonbacterial respiratory disease, so that the hemolytic streptococcus was only recognized during the period 1940-43 as a common cause of illness in those few camps where scarlet fever was occurring frequently. The importance of the case without a rash was not realized. Lastly, the Army and its consultants had not familiarized themselves with available civilian and military data which would have made it possible to predict with considerable accuracy those geographic areas in which outbreaks of hemolytic streptococcal infection and rheumatic fever might be expected.

Little information is available as to the situation during the prewar expansion of the Armed Forces. During 1941, outbreaks of scarlet fever followed by rheumatic fever occurred at Chanute Field, Ill., Scott Field, Belleville, Ill., and Fort Knox, Ky. The incidence of these diseases elsewhere in the Army during 1941 was low. Drs. James D. Trask, Francis F. Schwenkter, and M. Henry Dawson, of the Commission on Hemolytic Streptococcal Infections, Army Epidemiological Board (Board for the Investigation and Control of Influenza and Other Epidemic Diseases in the Army), visited each of these camps in November 1941. They noted that medical officers did not recognize the association of scarlet fever and streptococcal disease occurring without a rash nor did they connect either of them with rheumatic fever.4

The available records do not reveal that streptococcal disease was viewed with alarm during the period 1941-42, although the incidence of scarlet fever, in the total Army, during those years was comparable to that in 1943-44 when interest in infection by these organisms was very great. This was the result of the mildness of the acute streptococcal disease and of the failure to report accurately the occurrence of rheumatic fever prior to 1943.

The first detailed information in regard to the problem of rheumatic fever was obtained early in February 1943 when a survey of the continuing scarlet fever epidemic at Fort Francis E. Warren, Wyo., revealed that more than 100 patients with this disease had been hospitalized but neither correctly diagnosed nor reported to The Surgeon General.5 Subsequently, the rapid increase in size of installations in areas of high incidence of this dis-

3Circular Letter No. 123, Office of the Surgeon General, U.S. Army, 16 Dec. 1941, subject: Medical Department Form 86ab, Statistical Report (first section).
4Report, M. Henry Dawson, M.D., Director, Commission on Hemolytic Streptococcal Infections, Army Epidemiological Board, 24 Nov. 1941, subject: Report on Reconnaissance Trip to the Fifth and Sixth Corps Areas by Dr. James D. Trask, Dr. Francis F. Schwenkter, and Dr. M. Henry Dawson, Members of the Commission on Hemolytic Streptococcal Infections, November 11-19, 1941.
5Report, Lowell A. Rantz, M.D., Member, Commission on Hemolytic Streptococcal Infections, Army Epidemiological Board, to Col. S. Bayne-Jones, Office of the Surgeon General, 23 Feb. 1943, subject: Report of Epidemic of Scarlet Fever and Septic Sore Throat, at Fort Francis E. Warren.


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ease in Colorado and Utah was associated with epidemics of streptococcal infection and rheumatic fever. Additional surveys were made which again delineated the deficiencies in background and information on the part of medical officers in regard to streptococcal respiratory disease and its complications, although no control measures were recommended.6

During 1943, 6,710 admissions for rheumatic fever were reported from the Army in the United States. According to summaries of the statistical health reports, about 74 percent of these occurred in the Seventh and Ninth Service Commands. About 43 percent of all cases occurred in the States of Colorado, Utah, Idaho, Montana, and Wyoming. This large number of cases of a serious disease requiring prolonged hospital care and resulting in many separations from service attracted a very considerable interest in the offices of The Surgeon General of the Army and of the Air Surgeon. Three programs designed to acquire new knowledge about hemolytic streptococcal disease with special reference to its relationship to rheumatic fever and to control methods were instituted toward the end of 1943. All were conducted in the field with the active assistance and cooperation of many command and medical officers.

One of these programs was under the auspices of the Commission on Hemolytic Streptococcal Infections. Its purpose was the careful investigation of a large number of cases of hemolytic streptococcal respiratory infection for the purpose of defining the natural history, bacteriology, and immunology of these disorders. Associated with this group was the Commission on Air-Borne Infections, Army Epidemiological Board, whose main interest lay in the investigation of methods for control of airborne infection with particular reference to the hemolytic streptococcus. The results of these two Commission projects are described elsewhere.7 The third was the Army Air Forces Rheumatic Fever Control Program, Office of the Air Surgeon, which will be the subject of a later section of this chapter. These three programs were in active operation throughout 1944. Much new knowledge was acquired, but effective methods for the control of streptococcal disease and rheumatic fever were not forthcoming.

The Air Forces investigated intensively the role of sulfonamide prophylaxis during the early months of 1944. Streptococcal infection and rheumatic fever were notably reduced, and the use of this technique in certain defined situations, primarily for the prevention of these diseases, became established Army policy on 1 November 1944 with the publication of War Department Technical Bulletin (TB MED) 112. Unfortunately, by this time, strains of streptococci highly resistant to sulfonamides had emerged and were causing

6Report, Chester S. Keefer, M.D., Director, and Lowell A. Rantz, M.D., Member, Commission on Hemolytic Streptococcal Infections, Army Epidemiological Board, April 1943, subject: Report of Investigation of Rheumatic Fever at Fort Francis E. Warren, Cheyenne, Wyo., Lowry Field, Denver, Colo., Buckley Field, Denver, Colo., and Camp Carson, Colorado Springs, Colo.
7(1) History of the Commission on Air-Borne Infections, Army Epidemiological Board, 1941-45. [Official record.] (2) Commission on Hemolytic Streptococcal Infections, Army Epidemiological Board. [Undated.] [Official record.]


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disease among naval personnel where chemoprophylaxis had been widely used on a mass basis since December 1943.

Streptococcal infection continued to be epidemic throughout 1944, and 4,877 cases of rheumatic fever were reported in the United States. The highest incidence was again in the Sixth and Seventh Service Commands where 37 percent of the cases occurred. Twenty-four percent occurred in the States of Colorado, Utah, Wyoming, and Nevada, where relatively few troops were stationed. Streptococcal infection and rheumatic fever became an important problem among troops abroad for the first time in 1944 when 1,805 cases of the latter disease were reported. This represented a rate of only 0.47 per 1,000 per annum or approximately 38 percent of that among troops in the United States.

It became apparent, as the winter of 1945 began, that sulfonamide prophylaxis, the only method of proved value for the prevention of streptococcal infection and rheumatic fever, was no longer effective. Disease caused by resistant streptococci was epidemic in the U.S. Navy, and an outbreak of infection caused by similar strains had occurred at an Army Air Forces station. The entire problem was considered at a National Research Council conference on 28 February 1945. The failure of sulfonamide prophylaxis was detailed, and the hazards involved in its continued use were described. As a result of these experiences in the Navy, this technique was applied only selectively in the Army Air Forces and practically not at all in the Army Ground Forces. The possible value of penicillin prophylaxis was explored at another National Research Council conference on 20 March 1945, and studies for its evaluation under field conditions by the Army Air Forces were outlined but not undertaken.

The incidence of scarlet fever and rheumatic fever in the Army in the United States decreased in 1945 in spite of the absence of effective control measures. The incidence of streptococcal sore throat rose from 0.82 per 1,000 in 1944 to 3.64 in 1945. The effect was an increase in rate for the three conditions combined, from 3.98 per 1,000 in 1944 to 5.21 in 1945. Only 1,675 cases of rheumatic fever were reported. Two thousand and fifty additional cases occurred in the Army overseas. Another important National Research Council conference on streptococcal disease was held on 7 July 1945. The war ended in the autumn of that year, and information on the occurrence of this disease and rheumatic fever during demobilization is not available.

EPIDEMIOLOGY AND STATISTICS

Statistical and epidemiological data in regard to rheumatic fever and the causative hemolytic streptococcal infection has been presented in detail in another volume in the history of the Medical Department in World War II.8

8Medical Department, United States Army. Preventive Medicine in World War II. Volume IV. Communicable Diseases Transmitted Chiefly Through Respiratory and Alimentary Tracts. Washington: U.S. Government Printing Office, 1958.


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This information will not be recapitulated, but a summary is appropriate. Of about 18,000 reported cases of rheumatic fever, 34 percent developed in troops stationed in the Seventh Service Command at a rate about six times the rate for the total Army. Hemolytic streptococcal respiratory disease was epidemic in all of the high incidence areas for rheumatic fever, and a direct relationship between infection by these organisms and the rheumatic state was established by critical investigations.

Approximately 23 percent of all rheumatic fever admissions occurred in troops overseas. The rate was about two-fifths of that in the continental United States. In terms of rates, the worst experiences were encountered in the European, Mediterranean, and Middle East theaters. Three reports describing the disease as it occurred in the North African, Mediterranean, and European theaters have been published.9 The problem was much less in the China-Burma-India theater and in the Pacific and Latin American areas.

Rheumatic fever was most common in the months of January through June (77 percent of all cases) among men assembled for basic training, but occurred frequently during all seasons and among all types of personnel, particularly during the peak years of 1943 and 1944.

CLINICAL PICTURE

The clinical picture and natural history of rheumatic fever as it occurred among troops has been well defined in a few publications,10 and in much greater detail in reports of the activities of Army and Air Force rheumatic fever centers.11 These three reports, describing the disease as it was seen at Birmingham General Hospital, Van Nuys, Calif., Foster General Hospital, Jackson, Miss., and Torney General Hospital, Palm Springs, Calif., are most

9(1) Bland, E. F.: Rheumatic Fever and Rheumatic Heart Disease in the North African and Mediterranean Theater of Operations, United States Army. Am. Heart J. 32: 545-559, November 1946. (2) Claiborne, T. S.: Rheumatic Fever and Rheumatic Heart Disease in a General Hospital in North Africa. Med. Bull. North African Theat. Op. (No. 5) 1: 8, May 1944. (3) Foster, R. F.: Rheumatic Fever Here and in the European Theater of Operations. Northwest Med. 45: 503-506,  July 1946.
10(1) Wendkos, M. H., and Noll, J., Jr.: Symposium on Cardiovascular Diseases; A Survey of Rheumatic Fever in a Large Station Hospital. M. Clin. North America 28: 124-147, January 1944. (2) Wright, I. S.: Experiences With Rheumatic Fever in the Army. Bull. New York Acad. Med. 21: 419-432, August 1945. (3) Connor, C. A. R.: Experiences With Rheumatic Fever in the Army Air Forces. Am. J. Health 36: 236-243, March 1946. (4) Miller, J. H.: Rheumatic Fever at a Convalescent Center from March 1944 to March 1945. News Letter, Army Air Forces Rheumatic Fever Control Program, vol. 2, No. 10, p. 30, October 1945.
11(1) Report, Maj. Jules C. Welch, MC, Chief, Rheumatic Fever Section, Birmingham General Hospital, to The Surgeon General, attention: Director, Medical Consultants Division, 30 Nov. 1945, subject: Report on Studies on Rheumatic Fever. (2) Report, Capt. John F. McGinty, MC, Chief, Rheumatic Fever Section, Foster General Hospital, to The Surgeon General, attention: Director, Medical Consultants Division, 14 Dec. 1945, subject: Report on the Activities and Findings of the Rheumatic Fever Center, Foster General Hospital, Jackson, Mississippi, for the period from 2 Oct. 1944 to 1 Dec. 1945. (3) Report, Maj. E. P. Engleman, MC, Chief, Rheumatic Fever Center, Torney General Hospital, to The Surgeon General, attention: Col. Arden Freer, MC, Director, Medical Consultants Division, 11 Mar. 1946, subject: Report of Activities of Torney General Hospital Rheumatic Fever Center, 1 Mar. 1946.


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complete. Data derived therefrom are presented in table 33. It should be remembered that these were essentially convalescent hospitals and that the acute phases of the illness were not observed by the officers preparing these reports. The information about the early stages of the illness were compiled from abstracts of the station hospital records which accompanied the patients. These were usually quite complete. Examination of other reports, and the extensive experience of the author in the field during this period, indicates that table 33 and the commentary which is to follow presents an accurate picture of rheumatic fever as it occurred during World War II in the Army.

TABLE 33.-Clinical and historical information on rheumatic fever as observed in three U.S. Army general hospitals

[Percent expressed as percentages of cases in which the respective manifestations were observed]

Clinical data

Birmingham General Hospital (percent)

Foster General Hospital (percent)

Torney General Hospital (percent)

Past history of rheumatic fever

50.4

41.3

40.6

History of preceding respiratory infection

54. 9

40.1

84.5

Extracardiac manifestations:

     Arthritis

100.0

96.7

98.0

     Chorea

(1)

.5

.2

     Erythema multiforme or marginatum

5.4

2.2

2.5

     Erythema nodosum

2.7

1.8

(1)

     Subcutaneous nodules

1.5

1.1

.5

     Pneumonia

3.2

2.5

3.2

Cardiac manifestations:

     Apical systolic murmur 

11.8

13.0

45.0

     Apical diastolic murmur

2.7

8.4

2.5

     Aortic insufficiency 

10.3

7.7

5.0

     Pericarditis

5.6

3.3

3.7

     Cardiac insufficiency

0

.6

1.0

Electrocardiographic manifestations:

     Any abnormality 

53.5

27.7

47.6

          Prolonged AV conduction

26.8

24.6

28.2

          Abnormal T waves

10.1

3.1

14.0


Total number of cases 

262

807

401


1Not recorded.

Striking differences between the rates of occurrence of various clinical manifestations, notably those referable to the heart, reflect differences in interpretation of physical and laboratory signs by medical officers in the various hospitals. Rheumatic fever in the Army was an arthritic disease. Almost 100 percent of cases exhibited subjective or objective evidence of joint involvement. This simply means that the nonarthritic form of the


231

disorder was rarely recognized. Detailed studies beginning with the initiating streptococcal infection revealed a considerable number of cases in this category.12

A past history of rheumatic fever was obtained in 40 to 50 percent of all cases. This demonstrates that persons who have had rheumatic fever are much more likely to develop another attack after streptococcal infection than are nonrheumatics. A preceding upper respiratory infection, sore throat, or scarlet fever had been recognized by about half of the patients. Nearly all hospitalized patients had fever and malaise in addition to arthritis, but many other clinical manifestations of rheumatic fever were uncommon. Epistasis, erythematous skin lesions, pericarditis, pneumonia, and subcutaneous nodules occurred infrequently, although very often more than one of these signs of severe rheumatic fever was demonstrated in the same patient.

Evidence of carditis was obtained frequently. During the acute phase of the illness, the most common sign was an abnormal electrocardiogram. Prolonged AV (atrioventricular) conduction was demonstrated in about one-quarter of all patients and unequivocal T-wave abnormalities in an additional 3 to 14 percent. The average percentage for all patients was approximately 7 percent. Other abnormalities were reported by two of these hospitals to bring the total presenting electrocardiographic evidence of carditis to about 50 percent. The significance of many of these minor changes in the tracings is questionable.

Arrhythmias of any kind were observed in less than 0.5 percent of cases. Cardiac insufficiency developed in less than 1 percent and was almost always of short duration. Only three deaths from active rheumatic fever with heart failure are recorded.

Cardiac murmurs were heard frequently, but the significance of many is difficult to assess. Apical systolic murmurs were discovered in 45 percent of cases in one hospital but in only about 12 percent in the other two. Apical diastolic murmurs were uncommon. Evidence of aortic insufficiency was obtained in 5 to 10 percent of this group of patients. It was often inferred that these lesions were the result of the episode of rheumatic fever under study. This was undoubtedly so in some, but the author examined a number of men in whom valvular disease was present at the onset of the attack and was a residuum of a previous rheumatic episode. The characteristic murmurs had been overlooked at the time of induction into the Army. The available data, obtained at convalescent centers, do not permit ready differentiation between these two different situations.

Carditis was present in 40 to 50 percent of all cases if only positive electrocardiographic abnormalities and clear-cut new murmurs are considered to be indicative of its presence.

12Rantz, L. A., Boisvert, P. J., and Spink, W. W.: Hemolytic Streptococcic Sore Throat; The Poststreptococcic State. Arch. Int. Med. 79: 401-435, April 1947.


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EARLY TREATMENT AND COURSE

Documentary evidence in regard to the usual early treatment of rheumatic fever in the Army is not available. Prior to the autumn of 1944, these patients were treated in station hospitals until convalescence was sufficiently established to permit return to duty, separation from service, or transfer to a regional general hospital. During this early period, treatment was the responsibility of the chief of medicine in each station hospital, and varied greatly from one to another.

Great interest had been aroused at about this time in the use of very large amounts of salicylates in the treatment of rheumatic fever. Regimens were widely employed in which every effort was made to administer 10 gm. per day of sodium salicylate. The drug was not often given intravenously in the Army, but significant toxicity was frequently encountered.

The other important phase of the treatment of rheumatic fever involved rest and this was regularly utilized but in widely differing degrees. Strict bed rest over long periods of time and until all clinical and laboratory signs of activity had vanished was usual. Often, fantastic limitations of activity were imposed, and patients were forbidden to feed, wash, or shave themselves for many weeks. As late as 1944, War Department Technical Bulletin (TB MED) 97, dated 29 September, warned that the head of the bed should not be raised during the period of active disease, since absolute recumbency was believed to be an important phase of treatment. No chemoprophylaxis of streptococcal infections was undertaken before 1944.

The response to rest and the administration of salicylates in these patients was almost always excellent. Fever and arthritis regularly melted away so that the patients ordinarily felt very well within 2 to 3 weeks, and restrictions to bed became difficult. More prolonged and difficult illnesses did occur, particularly in the presence of pericarditis, but such cases accounted for less than 5 percent of the total. Heart failure was virtually unknown and its management was not a significant problem. Only 1 death due to rheumatic fever with heart failure occurred in 1,470 cases admitted to convalescent centers (table 33). The only data in regard to the duration of laboratory evidence of activity are from the Torney General Hospital experience. The erythrocyte sedimentation rate (Wintrobe) became normal in an average of 11.2 weeks. It was elevated for more than 4 weeks in 59 percent and for more than 9 weeks in 34 percent of 401 cases. Abnormal rates persisted for more than 5 months in only 12 percent.

Treatment of early rheumatic fever was doubtless much better standardized after September 1944 when TB MED 97 was published. This directive recommended about 1 month of bed rest at the station hospital followed by transfer to a convalescent center by air. Sodium salicylate was to be given in a dose of 16 gm. during the first 24 hours, followed by 10 gm. per day. High blood levels of the drug were doubtless attained, but toxicity


233

must have been commonplace with this regimen. Continuous prophylaxis with daily administration of a sulfonamide was directed.

The usual treatment of rheumatic fever with prolonged and often absolute bed rest until clinical and laboratory evidence of quiescence was obtained produced results which were not entirely satisfactory because cardiac neurosis was a frequent complication. One group working at an Air Force center13 utilized early ambulation in the treatment of 100 patients, continuing the administration of salicylates. The results were impressive in that the disease process subsided in the expected time without any increase in the incidence of chronic valvular heart disease. The experience of the author and his associates was similar in unpublished studies of a smaller group of patients.

LATE TREATMENT AND RESULTS

It was not until the middle of 1944 that much information became available in regard to the course of rheumatic fever in patients in the Army after the first few weeks of illness. Prior to this time, patients were separated from service, returned to duty after the disease had become quiescent, or forwarded to a general hospital. In the experience of the author, the first two events usually took place after about 6 months of treatment. Transfer to a general hospital was reserved for the very few patients whose disease was not ameliorated promptly or in whom the diagnosis was in doubt.

In Army Air Forces Letter 25-7, dated 29 April 1944, the Army Air Forces designated seven regional hospitals as rheumatic fever convalescent centers; namely, AAF Regional Station Hospital No. 1, Miami Area, Coral Gables, Fla.; Orlando Army Air Base, Fla.; Keesler Field, near Biloxi, Miss.; Davis-Monthan Field, Tucson, Ariz.; Las Vegas Army Air Field, Nev.; Hammer Field, Calif., and Santa Ana Army Air Base, Calif. In September 1944, the Army Service Forces followed suit and Birmingham, Torney, and Foster General Hospitals were so designated. All of these were in the southern part of the United States. The directives stated that patients were to be treated for about 1 month by bed rest and heavy salicylate therapy at the station hospital. At this time, it was anticipated that the acute manifestations of the disease would have subsided, and the patient was to be transferred by air to the center for additional rest and eventual rehabilitation. The number of available ambulance planes was not great, and it is not known how often this technique was employed. In the absence of air transport, patients were to be kept at the station hospital until fully convalescent and able to travel by train.14

13Robertson, H. F., Schmidt, R. E., and Feiring, W.: The Therapeutic Value of Early Physical Activity in Rheumatic Fever. News Letter, Army Air Forces Rheumatic Fever Control Program, vol. 2, No. 10, p. 17, October 1945.
14Army Service Forces Circular No. 360, 1 Nov. 1944.


234

Very complete statements about the operations of the general hospital centers have been preserved,15 and the following important facts about the late effects of rheumatic fever in troops have been obtained from them in addition to those that were used earlier in describing the nature of the acute illness.

Complete recovery without residua was the rule in these cases of rheumatic fever in young adults. Chronic valvular heart disease was the most serious complication. Table 33 shows that aortic insufficiency was demonstrated in from 5.0 to 10.3 percent; mitral stenosis in 2.5 to 8.4 percent; and mitral insufficiency in from 11.8 to 45.0 percent of all cases. Three difficulties arise in interpreting these data. One pertains to the varying diagnostic criteria that were applied, particularly in the recognition of mitral insufficiency. It is evident that these criteria were difficult to establish. They were less rigorous at Torney General Hospital than at the other two centers. A second stems from the fact that medical officers at the centers attributed all of the valvular disease present at the time of dismissal from the hospital to the current episode of rheumatic fever. There were many instances, as already indicated, when significant murmurs were present at the onset of the illness. These were certainly the result of previous attacks, the signs having been missed during the induction physical examination. No satisfactory data permitting detailed analysis of this important point are available. A third difficulty arises from the fact that the period of followup was short since it is known that clinical evidence of rheumatic valvular heart disease appears slowly and irregularly after an acute rheumatic episode.

One excellent study of 135 patients16 has provided valuable information as to the outcome after a period of observation of 4 to 8 years. Followup physical examinations revealed no abnormalities in 75.4 percent. An additional 16, or 11.8 percent, had only an apical systolic murmur, believed by the author to indicate the presence of mitral insufficiency. It is probable that few of this latter group had significant valvular disease. Mitral stenosis, or aortic stenosis, or insufficiency were discovered in only 12.8 percent of these patients. It has been suggested that not all of these lesions were the result of the rheumatic fever which occurred during military service. Only three of the entire group had definite enlargement of the heart and none showed evidence of cardiac insufficiency. The signs described above had been present at the termination of the rheumatic attack in all but one case. Thus, there had been an extraordinarily low incidence of progression of heart disease during this long period of observation. Of the group, 15, or 11 percent, had experienced a rheumatic recurrence since separation from the service. Chemoprophylaxis was not employed in any case.

It is disturbing to learn that definite heart consciousness, or neurocirculatory asthenia, as evidenced by precordial pain, dyspnea, and palpitation was

15See footnote 11, p. 229.
16Engleman, E. P., Hollister, L. E., and Kolb, F. O.: Sequelae of Rheumatic Fever in Men; Four to Eight-Year Follow-Up Study. J.A.M.A. 155: 1134-1140, 24 July 1954.


235

present in one-third of these patients. Anxiety neurosis was a more common complication of rheumatic fever in these individuals than valvular heart disease. Only a few of the study group described were disabled and nearly all were in school or were employed.

It is generally believed that clinical recovery from rheumatic fever is accompanied by complete disappearance of pain in the joints. It is of great interest that this was not so in the Army. Persistent arthralgia was commonplace, having been noted in 50 to 60 percent of the cases and having continued for as long as 6 years.17 Physical and roentgen examination of the joints never revealed any abnormalities after the first few weeks of the illness during which time effective salicylate therapy was instituted. The residual pain was often very disturbing to the affected individuals and interfered with resumption of their normal activity.

RECONDITIONING

Formal programs for the reconditioning of convalescent cases of rheumatic fever were not introduced in the Army until 1944 when treatment centers were established. Before this time, the station hospitals in areas where the disease was common were completely lacking in facilities for this purpose. Neither space, personnel, nor a suitable climate were available. This serious lack was an important contributing factor which led to the frequent appearance of cardiac neurosis. After the Army Service Forces and the Army Air Forces established centers, the situation improved greatly. Men were moved to these establishments fairly early in the disease, usually during the second or third month of illness.

Each of the centers located in general hospitals developed an elaborate program of supervised, graded, and gradually increased activity for convalescent patients. The official reports speak in glowing terms of the efficiency of these techniques. Complete recovery was hastened and cardiac neurosis minimized.18 Reconditioning was also an important aspect of the treatment at the Army Air Forces rheumatic fever centers,19 but information about results was not preserved. A formal study of the problem which was conducted in the physical fitness laboratory at Randolph Field, Tex., demonstrated that early activity proved to be safe and beneficial when accomplished with careful guidance and under the control of fitness tests.20

17(1) See footnote 16, p. 234. (2) Starr, M. P., and Kimbro, R. W.: Residual Arthralgia in Rheumatic Fever Patients. News Letter, Army Air Forces Rheumatic Fever Control Program, vol. 2, No. 2, pp. 17-21, February 1945.
18See footnote 11, p. 229.
19Ershler, I.: Convalescent Program for Rheumatic Fever. News Letter, Army Air Forces Rheumatic Fever Control Program, vol. 2, No. 1, p. 1, January 1945.
20(1) Karpovich, P. V.: Physical Reconditioning of Rheumatic Fever Patients. News Letter, Army Air Forces Rheumatic Fever Control Program, vol. 2, No. 4, p. 14, April 1945. (2) Karpovich, P. V., Starr, M. P., Kimbro, R. W., Stoll, C. G., and Weiss, R. A.: Physical Conditioning After Rheumatic Fever. [Official record.]


236

DISPOSITION

The problem of disposition of patients who had had rheumatic fever was a knotty one during the early years of World War II, and formal guidance was not provided by The Surgeon General. Each hospital made its own policy based on the experience of its medical officers. In general, men were retained in service after recovery if there was no evident residual cardiac damage. Often, the severity of initial illness was also considered. Some hospitals were separating all men in whom the diagnosis of rheumatic fever was made because it was believed that the chance of recurrence was too great if these individuals were retained in the service. An attempt was made to make the policy more uniform by the publication of Circular Letter No. 144 by the Office of the Surgeon General on 7 August 1943. Discharge was recommended for all men with residual cardiac damage and retention in service of all others who had fully recovered. This policy, in the experience of the author, was not closely followed by officers in the field who frequently tailored it to fit individual cases.

Army Air Forces Letter 25-7 defined the disposition of rheumatic fever patients in the Army Air Forces and stated that those who had made a complete recovery without residua should be returned to full duty. Those with evidence of cardiac damage were to be discharged unless they possessed special skills in which case they could be retained in the service and marked for limited duty. Various special situations were also considered in detail. Data on disposition of 410 cases of rheumatic fever by an Army Air Forces center show that 53 percent were returned to duty. Of those discharged, 67 percent had had a recurrent attack or activity continuing for more than 3 months. Only 23 percent were separated from service because of residual cardiac changes. This was less than 10 percent of the whole treatment group. No comparable directives from the Army Service Forces have come to the attention of the author, and it is of interest that the official publication on rheumatic fever, TB MED 97, does not discuss the important problem of disposition; this was to be the subject of a subsequent directive which was never issued.

Uniform disposition was not accomplished even by the three general hospitals which served as rheumatic fever treatment centers.21 At Birmingham General Hospital, the advice given in Circular Letter No. 144 was followed until September of 1945, and approximately 50 percent of the patients were discharged, the remainder being returned to limited duty. After that date, any evidence of carditis was accepted as grounds for separation. This included more than 80 percent of all cases. The staff at Foster General Hospital formulated its own policy and discharged all patients with multiple attacks of rheumatic fever in 1 year, those with any cardiac residua, and those whose disease remained active for more than 3 months. Approximately 50

21See footnote 11, p. 229.


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percent of cases assigned to this hospital received certificates of disability for discharge. The medical officer in charge of the rheumatic fever center at Torney General Hospital believed that troops who had had rheumatic fever were unsuitable for further military service because of the great risk of recurrence. He arbitrarily recommended 80 percent of them for discharge.

In retrospect, it is difficult to understand why a uniform policy for disposition of rheumatic fever patients was not established for the Army Service Forces hospitals by The Surgeon General. The varying criteria for discharge from the service were unfair to the patients and created a sense of frustration and insecurity among the responsible medical officers who were constantly in doubt as to the proper course to follow.

CONTROL

Rheumatic fever control programs were not undertaken by the Army Service Forces, although intensive research was carried out by the commissions working under the auspices of the Army Epidemiological Board; centers for care and rehabilitation were established.

The Army Air Forces, on the other hand, originated a full-scale rheumatic fever control program under direct authority from the Commanding General, Army Air Forces, in the fall of 1943. Its objectives22 were (1) recommendations for the use of sulfonamide prophylaxis for the control of respiratory infections and rheumatic fever, (2) adoption of uniform standards for the diagnosis of rheumatic fever, (3) coordination and standardization of bacteriological techniques in the study of the hemolytic Streptococcus, (4) establishment of a uniform convalescent program and followup studies on positive and suspected cases of rheumatic fever, and (5) consideration of special projects and investigations at various Army Air Forces posts.

All of these goals were accomplished with varying degrees of success. The greatest activity was in the area of study and control of streptococcal infection under objectives 1, 3, and 5. This work has been described in detail elsewhere.23 Uniformity of diagnosis and treatment was accomplished partly by educational activities directed toward the staffs of station hospitals, but more directly by the creation of centers for the care of patients with rheumatic fever and the use of air transport permitting transfer to these institutions at an early stage of the disease. Much was accomplished by the wide distribution of a monthly newsletter published at the AAF Regional Hospital, Mitchel Field, Long Island, N.Y., with the support of the Josiah Macy, Jr. Foundation of New York and edited by Capt. (later Maj.) Charles A. R. Connor, MC.

22The Denver Conference. News Letter, Army Air Forces Rheumatic Fever Control Program, vol. 1, No. 1, p. 2, August 1944. 
23See footnote 8, p. 228.


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Endless debate continued at various levels throughout the war in regard to the advisability of refusing induction to individuals with a past history of rheumatic fever because the number of such persons who developed recurrences of the disease was high. Mobilization Regulations No. 1-9 was variously modified. Between August 1940 and April 1944, active acute rheumatic fever or verified recurrent attacks of the disease in the past placed a man in the unacceptable group. The latter history was clearly not sought adequately by examining physicians at induction stations. In April 1944, the order was changed to include active acute rheumatic fever and verified single or recurrent attacks within 2 years. This order was not well designed since a definite attack of rheumatic fever has the same significance at any time in the life of the individual.24

RESEARCH

Clinical investigation of many phases of rheumatic fever was undertaken at numerous hospitals. The large amount of clinical material available to many highly skilled investigators permitted the rapid accumulation of information in regard to diagnosis, course, and treatment. Many reports of these studies were published but will not be reviewed here. The lack of special facilities in installations other than those specially supported by the Army Air Forces Rheumatic Fever Control Program or by the commissions of the Army Epidemiological Board prevented, for the most part, any fundamental work by these groups.

SUMMARY

Rheumatic fever was a common disease in the Army during World War II, particularly in certain geographic areas. It was observed in all degrees of severity, but the disease responded well to rest and the administration of salicylic acid and its derivatives. The course was usually monocyclic, and recovery in all but a few cases was complete within a few months. Valvular heart disease was a gratifyingly uncommon complication. The major problems encountered were those concerned with development of cardiac neurosis which was caused by overly severe restriction of activity, apprehension on the part of the medical officers in charge, and inadequate programs for convalescent rehabilitation. This situation was greatly  improved during the last 2 years of the war by the creation of treatment centers.

Investigation of many aspects of the prevention and management of rheumatic fever was carried out. Much pertained to the study of the close relationship between infection by group A hemolytic streptococci and the rheumatic state and to measures for the control of streptococcal infection.

24It is certain that young adults who have had rheumatic fever are more likely to experience recurrences when exposed to streptococcus infection during military service than are nonrheumatics. They should be identified with care at the time of induction and a chemoprophylactic regimen instituted at once. This should permit them to contribute fully to the military effort.

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