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Richard T. Smith, M.D.
The importance of arthritis and other rheumatic diseases as a cause of disability and noneffectiveness in military personnel was recognized by the War Department in 1942, for although arthritis did not account for a large percentage of illnesses in the Army, it had been found to be one of the most disabling. In anticipation of a formidable number of cases of rheumatic diseases, and in an effort adequately to diagnose, treat, and salvage as many military personnel as possible, not only for the World War II period but also for the long-range national economy, tentative steps were taken in the latter part of 1942.
The Surgeon General and his staff, with the cooperation of the American Rheumatism Association, formulated a plan for the establishment of one or more rheumatism centers for the Army when the need for them should arise. These were to be designated as centers for chronic rheumatic diseases and centers for rheumatic fever, specifically for the care of the difficult or progressive cases and the handling of diagnostic problems.
Toward the end of 1943, it became apparent that a center for the treatment of chronic arthritis would be needed. Therefore, on 17 December 1943,1 the Army and Navy General Hospital at Hot Springs, Ark., was designated as a center for the diagnosis and treatment of rheumatic diseases. A second center for chronic rheumatic diseases was authorized on 25 August 1944, at Ashburn General Hospital, McKinney, Tex., to relieve the flow of patients at the first center.2 At the same time, the following three centers were designated for the care of soldiers with rheumatic fever: Birmingham General Hospital, Van Nuys, Calif.; Foster General Hospital, Jackson, Miss.; and Torney General Hospital, Palm Springs, Calif.
CENTERS FOR RHEUMATIC DISEASES
Army and Navy General Hospital
The first rheumatic disease center had its beginning as a general hospital, established in 1882. On 20 June 1882, Congress passed an act appro-
Headquarters, Army Service Forces, Washington, D.C., to Commanding Generals, all
service commands and Military District of Washington, 17 Dec. 1943,
subject: General Hospitals Designated for Specialized Treatment.
priating $100,000 for the erection of an Army and Navy Hospital on a Government reservation near Hot Springs, Ark. War Department General Orders No. 72, 5 July 1882, officially established the Army and Navy General Hospital.3 The cornerstone was laid in 1883 on a site of approximately 15 acres. The hospital was opened for occupancy on 17 January 1887.4 From that time until the last additional building was added on the hospital grounds in 1927, there was a daily average of 300 patients.
A new building for the Army and Navy General Hospital was started in 1941 and completed in 1943, costing approximately $1,500,000. It was a six-floor modern building with a total bed capacity of 518.
A short time after war was declared in 1941, the hospital underwent new expansion which more than doubled its bed capacity to a total of 1,220. The Eastman Hotel situated across the street from the hospital was purchased by the War Department on 13 October 1942. Considerable rehabilitation was required in the hotel but it was ready for occupancy as the hospital annex, connected to the main building by an overhead passageway across Reserve Avenue, on 5 December 1943. The annex contained 466 rooms. It was planned to be used exclusively for the housing and care of convalescent patients, which would minimize any fire risk although the building had been "fireproofed" throughout. In addition, other properties were purchased, including the Eastman Hotel garage and the Hot Springs Hotel.
The reservation of 24.24 acres on the southwest slope of North Mountain, approximately 650 feet above sea level, overlooked the main intersection of Hot Springs. By utilizing the barracks and quarters which were established, before the beginning of World War II, for a technicians' school, a rehabilitation center for ambulatory patients was also established. In addition, there were quarters for nurses, Wacs, and enlisted men; seven homes for officers; and quartermaster and all other facilities for a self-contained army post.
When the Army and Navy General Hospital (fig. 61) was designated a center for the diagnosis and treatment of rheumatic diseases among American soldiers, it and any others that might be established in the future were designed, as previously mentioned, for the care of difficult or progressive cases, or for the handling of diagnostic problems.
It was believed that the majority of soldiers who developed rheumatism would not be transferred to a center such as the Army and Navy General Hospital. Patients with transient muscular rheumatism, mild rheumatic fever without carditis, or acute traumatic or specific infectious arthritis could be handled effectively in adjacent station or regional hospitals.
The designated aims for a rheumatism center were-
1. Accurate diagnosis: to provide a diagnostic center where difficult
3Unless otherwise indicated, all data
on the Army and Navy General Hospital are from "Annual Reports, Army and
Navy General Hospital, 1941-45."
FIGURE 61.-Army and Navy General Hospital, Hot Springs, Ark. (1) Public bathhouses. (2) Army and Navy General Hospital bathhouse and physical therapy department. (3) Nurses' and Wacs' quarters. (4) Advanced reconditioning. (5) Homes for staff officers. (6) Enlisted men's recreation hall. (7) Rehabilitation area. (8) Quartermaster and utilities. (9) Enlisted men's barracks. (10) Fire station in Eastman Hotel garage. (11) Eastman Hotel Annex. (12) Walkway across Reserve Avenue, connecting 2d floor of hospital to 4th floor of annex. (13) Army and Navy General Hospital. (14) Central Avenue, Hot Springs, Ark.
cases can be studied by special methods and by medical officers with a special knowledge of rheumatic diseases.
2. Intensive treatment: to provide special facilities for the treatment of the more severe or progressive cases.
3. Prompt disposition: to accomplish as great a reduction in hospitalization time as is consistent with adequate treatment.
4. Increase salvage: to restore to duty, if possible, all men with "cured" or "arrested" disease.
5. Rehabilitation: to educate or rehabilitate for civilian life those whose disability necessitates discharge from the Army.
6. Application of newer advances in treatment.
7. Appropriate clinical studies of patients while under treatment.
8. Long-range economy, an incidental, but important aim: to reduce the costly need for disability pensions and prolonged hospitalization in veterans' facilities.
The Army and Navy General Hospital, the Army's oldest general hospital, was chosen because of its past history and excellent facilities. The
adjacent Hot Springs which, since 1887, had been a mecca for rheumatic personnel of the Army, was a natural choice. An outstanding advantage of establishing a rheumatism center in a large general hospital provided varied medical and surgical specialties which were necessary for proper knowledge and complete treatment of rheumatic diseases. This provided specialists in all fields of medicine to support the extreme specialization in the rheumatic diseases.
The rapid growth of the rheumatism center is evidenced by the daily census of the rheumatic disease section, which rose from 56 patients in January 1944 to a total of 704 patients in October 1944. This is well demonstrated in table 85 where the total admissions to the rheumatic disease section in 1943 was 556 patients, or 29 percent of the total admissions for that year. In 1944, it had increased to 3,105 rheumatic patients, 63.8 percent of the total 4,868 admissions in the year. Between 1 January and 30 June 1945, an additional 2,210 rheumatic patients were admitted, or a total of 5,315 in 18 months.
1Hospital designated a specialized center for treatment of
rheumatic diseases, 17 Dec. 1943.
Another evidence of the activity of the rheumatic disease section is seen in table 86. In 1942, of the 15 officers of the medical service, 2 were assigned to the care of rheumatism patients, utilizing 111 beds. For 1944 and 1945, the professional personnel for the section increased to 9 and 18, respectively, with an allotment of 600 beds for these special patients. Other facilities, such as the physical therapy department, the occupational therapy department, a braceshop, and the physical rehabilitation area, also were expanded.
Organization of the rheumatic disease section.-During 1944-45, the rheumatic disease section of the Army and Navy General Hospital reached its maximum in space and function. With a total of 600 beds allocated to this section (exclusive of beds for female patients), 90 percent of these
were for ambulatory patients and were situated in the Eastman annex. Ambulatory enlisted rheumatic patients were housed in seven complete wards in the annex while nonambulatory patients were housed in one complete ward in the hospital building proper. Ambulatory rheumatic officers were housed in two complete wards in the annex, while nonambulatory rheumatic officers were cared for in the officers' ward in the main building. Female rheumatic patients were assigned to the female ward. There were actually eight complete wards ranging from 60 to 83 beds, and parts of five other wards that were utilized for patients assigned to this section.
Between 1 July 1944 and the end of 1945, the daily census ranged between 500 and 700 patients present in the section. In addition, there were between 150 and 350 rheumatism patients on furlough at all times.
Source: Annual Reports, Army and Navy General Hospital, 1942-45.
The ratio of only 60 beds for nonambulatory patients and 540 for ambulatory patients occurred partly owing to necessity and partly by design. The Eastman annex, containing 90 percent of all the beds in the rheumatic disease section was not considered a suitable building for completely bedfast patients. This constituted the necessity. It was the philosophy of the staff of the rheumatic disease section, and the design, that (1) less disability and permanent crippling would occur if joints were not severely limited by excessive rest; (2) less rehabilitation and reconditioning would be required if patients were forced to be active; and (3) morale would be higher if the severely ill bed patients were physically separated from the ambulatory patients. An additional benefit also occurred in that the period of hospitalization was considerably shortened.
Despite the fact that more than half of the patients transferred to the Army and Navy General Hospital arrived as litter patients or had been only semi-ambulatory at the time of admission, most of them were informed that they were now ambulatory and were assigned to wards in the annex. As might be expected, many of those newly designated ambu-
latory patients were most unhappy with their new status. This rapidly changed when they realized that only in this category were they eligible for afternoon or evening passes, or for furloughs.
All special areas of the hospital were utilized for the best treatment of the patients. Constant and frequent consultation with the orthopedic department was essential in providing the best treatment to the patients. Where necessary, corrective or diagnostic operative procedures were carried out. The physical therapy department participated in the treatment of most patients. All laboratory and diagnostic services were utilized for the best benefit of the patients.
The personnel of the section on rheumatic diseases in 1944 consisted of nine medical officers. Three officers were qualified as specialists in rheumatic diseases, one of whom was the chief of the section; one was a partially trained officer; and five officers were undergoing training (table 86). The director of the rheumatism center was also the chief of the medical service.
In 1945, the staff of the section (fig. 62) was increased to 18 officers. These included five qualified specialists in rheumatic diseases, four partially trained officers, and nine officers undergoing training.
Ashburn General Hospital
Within the first few months of 1944, it became apparent that an additional rheumatism center would be needed. The second rheumatism center, as already mentioned, was established at the Ashburn General Hospital.5 This hospital became operative as a rheumatism center, on 1 September 1944. There were 729 beds allocated for arthritis. On 1 January 1945, by converting regular barracks into wards, the bed capacity for rheumatic disease patients was increased to a total of 1,661. This hospital reached its peak of admissions to all sections of the hospital on 29 August 1945, when there was a total of 2,852 patients. Thereafter, there was a steady decline of admissions and census in the hospital until 12 December 1945, at which time, with only 17 beds occupied, the hospital was declared surplus. During the first 8 months that Ashburn General Hospital functioned as a rheumatism center, admissions to the rheumatic disease section averaged more than 400 a month. During 1945, a total of 3,534 patients were admitted to the section.
The rheumatic disease section consisted of 14 wards when it first began operation on 1 September 1944. The medical personnel consisted of a chief of the section, assisted by four medical officers. This was an inadequate staff for the size of the section, requiring the chief of the section to take personal charge of wards in addition to his other duties.
5Unless otherwise indicated, all data on Ashburn General Hospital are from "Annual Reports, Ashburn General Hospital, 1944-45."
FIGURE 62.-Members of the Medical Service, Rheumatic Disease Section, Army and Navy General Hospital, Hot Springs, Ark., with Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine, SGO, Brig. Gen. Ralph H. Goldthwaite, Commanding General, Army and Navy General Hospital, and Col. Walter Bauer, MC, Consultant in Medicine, Eighth Service Command, at a meeting, 22 January 1945, at the Army and Navy General Hospital. Front row (left to right): General Goldthwaite, General Morgan, Colonel Bauer, and Lt. Col. Philip S. Hench, MC, Chief of Medical Service and Director, Rheumatism Center, Army and Navy General Hospital. Back row (left to right): Lt. Edward F. Rosenberg, MC, Capt. Richard T. Smith, MC, Maj. Edward W. Boland, MC, Chief, Rheumatic Disease Section, Maj. James O. Finney, MC, Capt. Nathan E. Headley, MC, Maj. Howard C. Coggeshall, MC, and Lt. Harley E. Cluxton, MC.
The following objectives were the guide for organizing the section:
1. To facilitate the prompt and proper care of patients upon admission to the hospital.
2. To give all patients received from overseas a convalescent furlough as soon as it could be determined such would not aggravate their physical condition.
3. Definitive treatment, to emphasize teaching all patients the nature of their disease and the way to care for themselves in their homes.
4. To bring all patients with interesting or puzzling features of disease before conferences of the entire group of medical officers, and particularly to utilize the services of the orthopedic surgeon and the neuropsychiatrist in this connection.
5. To keep adequate records of each patient in order to contribute as much as possible toward increasing knowledge of the type of rheumatic diseases observed.
During 1945, the rheumatic disease section increased in size to four groups of six to eight wards. Each group of wards was under the direction of one officer trained in the care of rheumatic diseases, who supervised and taught the ward officers under his charge.
When patients were admitted to the hospital, they were placed in classification wards. The type and severity of their disease was estimated. Then, within 48 hours, they were transferred to another ward where definitive treatment was started. Frequently, patients were permitted to proceed on their initial oversea furlough directly from these classification wards.
The officers' and women's section of the hospital consisted of seven wards with three to six medical officers. Most of the patients had a rheumatic disease. One of the officers assigned to the section, trained in the care of rheumatic diseases, acted as consultant for the entire section.
The conditions imposed upon military personnel by military combat operations influenced the probabilities of an increased incidence of many of the rheumatic diseases. The factors which would increase the hazards of fibrositis, psychogenic rheumatism, and rheumatoid arthritis are emotional disturbances, repeated and prolonged exposure to extremes of temperature and dampness, poor personal hygiene, exposure to respiratory and other infections, musculoskeletal strain, fatigue, and joint trauma. An increased prevalence of respiratory infections would tend to increase the incidence of rheumatic fever. The rate of traumatic arthritis would increase, since injuries to joints would be more common. Increased exposure to, and the occurrence of, gonorrhea would produce more gonorrheal arthritis. Infectious arthritis with penetrating injuries to joints would be more common.
Climatic conditions, often thought to be an important factor in the frequency and distribution of the rheumatic diseases, were of little import. The total incidence and that of the various rheumatic conditions was essentially the same for those theaters and areas with wide differences in climate, such as the continental United States, the Mediterranean theater,
and the Southwest Pacific Area (table 87). The highest rate of admissions (21.21) was for the North American theater (including Alaska and Iceland), while the lowest rate (10.72) was for the European theater, with a comparable climate. The next highest admission rates were found in the Middle East (18.61) and the Southwest Pacific theaters (15.24).
When the original planning for rheumatism centers was undertaken, there was no guide by which a possible need could be determined. Much of the future need had to be arrived at by considering an "anticipated incidence" based upon World War I and various peacetime studies. There were many pitfalls in attempting to compare civilian rates with the Army rate; namely, the relative vagueness and unreliability of the diagnostic groupings and the differences in age groups being considered since the Army consisted of young males. In addition, the Army diagnostic criteria differed considerably in the two wars, making a direct comparison impossible.
The first civilian study, the Hagerstown Morbidity Study, begun in 1921, showed a rate of 20.8 cases for 1,000 population per year.6 At this
6Hagerstown Morbidity Study, U.S. Public Health Service, Hagerstown, Md.
rate, a total of 530,000 cases of rheumatic disease would have occurred during the war. The U.S. Public Health Service survey, 1933-36, developed a rate of 22.7 cases per 1,000 population per year,7 or a possible 578,000 cases for the duration of the war. On the other hand, a rate of 14 per 1,000 per year, arrived at by the Massachusetts survey in 1933,8 suggested a total of 357,000 for the same period of hostilities.
During World War I, there were no special centers for rheumatic diseases, although there were 84,550 admissions with a primary diagnosis of one of the rheumatic diseases.9 However, with the addition of those patients having a rheumatic disease as the secondary diagnosis, the total incidence was approximately 107,000, or 26 per 1,000 average strength per year.10 On this basis, the incidence of rheumatic diseases for World War II would have amounted to approximately 659,000.
It is quite evident that any effort to arrive at a realistic rate on the basis of the preceding figures would have been impossible. An average of the four rates amounts to 21.25 per 1,000 per year. The rate which more nearly approximated the actual figure was the Hagerstown rate of 20.8. The true incidence rate for World War II was 20.7 cases per year per 1,000 average strength, or 528,300 cases during the years 1942-45.11 This consisted of those patients primarily admitted to hospitals for a rheumatic condition, as well as those cases secondary to or concurrent with other admission diagnoses.
Disqualification for Military Service Because of Rheumatic Diseases
Any direct comparison between rejection rates of applicants for enlistment in World War I and World War II must be considered with caution. Some of the more important sources of error are: (1) Differences in ages in the two wars, (2) differences in diagnostic criteria, and (3) differences in the prevailing medical standards. These data should not be used to draw definite conclusions in regard to trends in the prevalence of the rheumatic diseases.
The examinees of World War I were younger than those in World War II. Therefore, table 88 shows a comparison between those rejected for military service in World War I and the age group of 20-24 years in World War II. It is clearly seen from this table that the medical standards were different in the two wars; for instance, gonococcus infection of a joint, limitation of motion, and sacroiliac deformities were reasons for
7Preliminary Reports, The National Health Survey: 1935 to
1936, Sickness and Medical Care Series. Bulletins Nos. 1 to 6, U.S. Public
Health Service, Washington, D.C.
disqualification in World War II but not in World War I. The increase in the number of disqualifying defects should not be interpreted as an increase in their incidence, but rather improvement in the diagnostic criteria at the time of World War II.
[Rate expressed as number of disqualifications per 1,000 examinees]
1Love, Albert G., and Davenport, Charles B.:
Defects Found in
Drafted Men. Washington: Government Printing Office, 1920, table V.
Hospital Admissions for Rheumatic Conditions
The disparity in the diagnostic terms for the rheumatic diseases in World War I and World War II interferes with a direct comparison of hospital admissions by diagnoses (table 89). In World War I, all arthritis, including osteoarthritis, was grouped under the single term "arthritis," while six different classifications for "arthritis" (acute, chronic rheumatoid, osteo, other, tuberculosis, and gouty) were employed in World War II. In addition, data for "bursitis" separately are not available for World War I.
The term "admissions" in the various tables refers to the specified diseases reported as the primary cause for the patient's admission to a medical treatment facility. There were, in addition to those admissions indicated in table 89, other diagnoses of specific rheumatic diseases, secondary to or concurrent with some other admission diagnoses. If these additional diagnoses were added to the primary rheumatic hospital admission rates, the total incidence rate for World War I would have been 25.9 per 1,000 per year and for World War II, 20.7.
[Rate expressed as number of cases per annum per 1,000 average strength]
1The Medical Department of the United
States Army in the World War. Washington: U.S. Government Printing Office,
1925, vol. XV, Statistics, pt. 2.
The admission rates for rheumatic diseases in the various theaters is shown in table 87. Some isolated but incomplete reports of the incidence of certain rheumatic diseases are available from a few theaters; namely, a portion of the Latin American area, the North African theater, and the western portion of the Central and South Pacific theater.
In the Panama Canal Department, of the Latin American area, Gorgas General Hospital had a total of 23 patients with rheumatoid arthritis between 1 January 1940 and 1 October 1945; an additional eight cases were reported from other military hospitals of the Department for the period 1 January 1941 to 31 December 1945.12 Most of the patients had mild arthritis; 14 of the 23 from Gorgas General Hospital were returned to the United States for full evaluation and treatment.
In the Antilles Department,13 also of the Latin American area, from 1942 to 1 October 1945, a total of 225 patients were admitted with rheumatoid arthritis to the 161st General Hospital, San Juan, Puerto Rico. The majority of these patients were separated from the military service.
12Professional History of Internal Medicine in World War
II, 1 January 1940 to 1 October 1945, The Panama Canal Department, vol. I, p.
73. [Official record.]
The 359th Station Hospital, on Trinidad, however, had only 100 admissions with a primary diagnosis of arthritis and 35 admissions in which arthritis was a secondary diagnosis. Fifty-two of the first group and 15 of the second group, or a total of 67, were transferred to general hospitals. The remaining 68 patients were returned to duty. Only 15 of the 135 patients were diagnosed as rheumatoid arthritis.
In the Mediterranean theater, in a group of 10 general hospitals up to 1 December 1944, 3,260 patients were admitted with a diagnosis of arthritis, or 1.8 percent of the total 177,317 hospital admissions.14 With respect to a comparison between those patients admitted for a diagnosis of arthritis versus the total number of admissions to the medical services of three general hospitals (70th, 45th, and 12th), there were 1,157 patients with a diagnosis of arthritis, or 4.1 percent of the 28,251 medical patients.
Disposition of patients with arthritis in selected general hospitals from the Mediterranean theater is presented in table 90. The data collected from the 10 general hospitals were obtained by written questionnaires. The information from the 45th General Hospital, Rabat, French Morocco, came from an examination of the records of the medical service. These are compared with the dispositions of the remainder of medical patients in the 45th General Hospital, as well as with the dispositions for all patients hospitalized for medical reasons in the entire theater. An inference can be drawn from this table that slightly less than half of those patients with arthritis reaching a general hospital in that theater were evacuated, and approximately another one-fourth were reclassified for limited service. When compared with the medical admissions for the entire
Source: Short, C.L.: Arthritis in the North African and Mediterranean Theater of Operations, table 6. [Official record.]
14Short, C. L.: Arthritis in the North African and Mediterranean Theater of Operations, table 3. [Official record.]
theater, it is quite evident that the arthritic is much more vulnerable in these respects.
A geographic distribution of admissions for arthritis and arthralgia in five islands of the Western Pacific Base Command of the Central and South Pacific theater is shown in table 91, as compared with the total medical admissions for the same islands. Most medical officers believed that the symptoms causing hospital admission were directly related to the high humidity in this area of the Pacific regardless of whatever the underlying process might have been.15 This is of particular interest, for Iwo Jima, the driest of the islands in the Western Pacific Base Command, had the lowest incidence of arthritic conditions. No specific data were presented in regard to the disposition of these patients. In general, the criteria for evacuation were the severity of symptoms and the persistence of sedimentation rate elevation, further influenced by such factors as the amount of time spent overseas and the amount of combat duty. Patients for evacuation were usually classed as "arthritis," therefore, statistics of diagnosis may be considered as unreliable.
Source: Turner, Glenn O.: History of Internal Medicine of the Western Pacific Base Command, table 4a. [Official record.]
Disposition of Rheumatic Diseases
During the period 1942-45, 64,619 enlisted and commissioned personnel were released from the Army because of rheumatic diseases (table 92). Of this number, there were 50 deaths. During this same period, 886,127 soldiers were separated from the service because of nonbattle disability. The 64,569 rheumatic patients separated comprised only 7.3 percent of the total for nonbattle causes.
15Turner, Glenn O.: History of Internal Medicine of the Western Pacific Base Command, 1945. [Official record.]
The daily average noneffective rate during 1942-45, due to nonbattle causes was 36.68 per 1,000 per average strength. The noneffective rate for rheumatic diseases was 1.28, or 3.5 percent of the total. The diseases "acute arthritis," "chronic rheumatoid arthritis," "hypertrophic arthritis," and "other and unspecified arthritis" caused more noneffectiveness than all other rheumatic diseases.
TABLE 92.-Disability separations, deaths, and noneffectiveness due to rheumatic diseases1 in the U.S. Army, 1942-45
[Preliminary data based on sample tabulations of individual
1Includes rheumatic diseases directly attributable to
One of the outstanding purposes of the rheumatism centers of the U.S. Army was to conserve personnel, not only for military service but also for civilian life. Of 894 dispositions by certificates of disability for discharge at the Army and Navy General Hospital in 1944, 501 (approximately 50 percent) were due to rheumatic diseases that made the individuals unfit for further service. In 1945, 1,030 of 1,576, or about 56 percent, were also lost from service through certificate of disability for discharge. Every consideration was given to the possibility of conserving each of these soldiers for further military service, on limited service if full duty was not possible. However, even limited duty can prove strenuous for military personnel with musculoskeletal deformities or disabilities. None of those separated from service was considered suited to work as much as 8 hours a day.
Most of the patients with fibrositis, "psychogenic rheumatism," rheumatic fever, or gonorrheal arthritis were returned to duty, while the majority of those with rheumatoid arthritis, osteoarthritis, or gout were separated from service. Generally, those patients with osteoarthritis were older commissioned or noncommissioned officers who had had long service in the Army. Soldiers suffering from gout or gouty arthritis were unsuitable for military life because of the impossibility of following a medical or dietary regimen, and of the ever-present danger of provocative physical trauma. The impracticability of continuing in military service would be particularly true if there were frequent recurrences of acute gouty arthritis even in persons on limited military service.
The disposition of rheumatic patients by diagnosis at the Army and Navy General Hospital is shown in table 93. These are not consecutive admissions but rather groups of patients including enlisted men and officers with various diagnoses. No final statistics are available regarding the disposition of patients with rheumatic diseases from Ashburn General Hospital. Its 1944 Annual Report, however, contained the following statement: "* * * the disposition of by far the greater number of patients with rheumatoid arthritis has been separation from the Service upon certificate of disability and it is probable that this will continue to be the case."
Source: Hench, P. S., and Boland, E. W.: The Management of Chronic Arthritis and Other Rheumatic Diseases Among Soldiers of the United States Army. Ann. Int. Med. 24: 822, May 1946.
In the early period of World War II, most of the rheumatic disease patients admitted to the Army and Navy General Hospital had been received from various military establishments throughout the continental United States, but by early 1944, the majority of patients were arriving from oversea hospitals. Many were returned by ship from the South Pacific Area or from the European theater. Others were transported by ambulance planes of the Military Transport Command. Some patients had arrived by plane within 4 to 6 days after leaving hospitals in the South Pacific (for example, within 4 days from Saipan to Hot Springs); others within 3 to 7 days from England, Italy, or France (for example, from Paris to Hot Springs in 3 days). This rapid evacuation of rheumatic soldiers from oversea hospitals to a hospital equipped especially for their needs was a strong morale builder among the military personnel and their very anxious relatives. In addition, the promptness of diagnosis and disposition and the adequate treatment programs also raised and maintained morale.
Unfortunately, no official final figures on the relative incidence of the rheumatic diseases are available from the Army and Navy General Hospital. From 1942 to 1945, there were 7,719 rheumatic disease admissions, of which 86.1 percent (6,647) occurred during 1944-45 (table 85). Very definite information can be gleaned from a survey of the first 2,000 consecutive admissions to the rheumatic disease section and the first 5,000 admissions (table 94). Since the patients sent to the rheumatism centers are selected, a census from such installations does not reflect a relative incidence of the rheumatic diseases in the Army as a whole. All the common forms of rheumatic diseases, as well as most of the rarer types, were seen at this rheumatism center.
As might be anticipated, rheumatoid arthritis presented the largest group of patients, affecting approximately one-third of all those admitted to the section. Approximately one-fifth of the patients admitted as "rheumatic" had no evidence of organic skeletal disease. These patients were suffering from a psychoneurosis which was manifested by musculoskeletal symptoms, a condition which had been termed by some as "psychogenic rheumatism,"16 and by others as "psychoneurotic rheumatism,"17 or "psychosomatic rheumatism."18 The relative use of soldiers was largely responsible for the low incidence of gout and gouty arthritis. The highest incidence for gout was 1 percent as compared with approximately 4 to 5 percent frequently seen in civilian rheumatism clinics. The incidence
16Boland, E. W., and Corr, W. P.: Psychogenic Rheumatism.
J.A.M.A. 123: 805-809, 27 Nov. 1943.
1Annual Report, Army and Navy General Hospital, 1944.
of gonorrheal arthritis was quite low because of the chemotherapy which was available.
Approximately one-third of the patients with rheumatoid arthritis had rheumatoid spondylitis. This relative incidence was surprisingly high and in considerable contrast with experiences in civilian practice. For many months at a time, there were between 70 and 100 cases of rheumatoid spondylitis in the hospital. This rather high incidence was probably due to three factors: (1) Rheumatoid spondylitis affects males much more often than females and especially young males of military age (18-30 years); (2) the early symptoms of the disease, including vague intermittent low back pain, are difficult to evaluate and an early diagnosis had frequently not been made, including failure to recognize it in young men as they were being inducted into the Army; and (3) the strenuous physical exertion of army life and the training to which they were exposed probably soon aggravated the symptoms and revealed the early previously undiagnosed patients. The incidence of the various rheumatic diseases at the Army and Navy General Hospital and at Ashburn General Hospital are within about the same limits (table 95).
TABLE 95.-Comparison of incidence of various rheumatic diseases among first 2,000 cases at Army and Navy General Hospital1 and first 800 cases at Ashburn General Hospital2
1Annual Report, Army and Navy General Hospital, 1944.
PROBLEMS OF DIAGNOSIS
The first stated aim of the rheumatism centers was to provide "accurate diagnosis" (p. 478). The absolute necessity of this aim was indicated by the first admissions to the centers and emphasized and reemphasized with each succeeding group of admissions. The commonly stated transfer diagnoses of "acute arthritis," "chronic arthritis," or simply "arthritis" were inadequate for instituting proper therapy, estimating prognosis, or planning for the disposition of the patients. In fact, these terms often constituted no diagnosis at all. There were scores of patients with a diagnosis of "arthritis" who had no arthritis at all. There were patients who were presumed to have "osteoarthritis" when they really had rheumatoid arthritis or vice versa. Very few patients with gout were correctly diagnosed. A large proportion of soldiers transferred because of "muscular rheumatism," "myositis," or "fibrositis" were suffering from "psychogenic rheumatism." These errors were not reflections on individual medical officers but rather revealed the inadequate diagnostic level of the medical profession in rheumatologic matters, pointing up the extreme need for a wider and more critical understanding of the fundamentals of diagnosis in disease of the joints.
There were also several special problems relating to differential diagnosis. These included post-gonorrheal rheumatoid arthritis versus gonorrheal arthritis and psychogenic rheumatism versus fibrositis.
Post-Gonorrheal Rheumatoid Arthritis Versus Gonorrheal Arthritis
That rheumatoid arthritis could be precipitated by gonorrheal infection, just as by tonsillitis, influenza, or some other acute infection, was not
well understood. In addition, the possibility that a very mild or non-symptomatic rheumatoid arthritis could be aggravated by an acute genital gonorrhea was usually overlooked. Neither of those instances should have been considered as intimately involved with a venereal disease, but simply as rheumatoid arthritis precipitated by an acute infection which just happened to be a venereal disease. It was reported in the First World War by Pemberton and his associates19 that approximately 1 percent of the cases of chronic arthritis seen among soldiers began in close relationship with the onset of gonorrhea.
Proved gonorrheal arthritis among American soldiers was apparently rare. Many more patients with a rheumatoid arthritis, precipitated or aggravated by a gonorrheal infection, were seen at the arthritis centers. Unfortunately, the majority of these patients were improperly labeled gonorrheal arthritis. They were unsuccessfully treated for this condition, before transfer, with sulfonamides, penicillin, or fever therapy, then sent to the center with a diagnosis of "gonorrheal arthritis resistant to penicillin and/or sulfonamides." Almost invariably those so-called cases of "gonorrheal arthritis resistant to chemotherapy" turned out to be rheumatoid arthritis, as shown by their subsequent course, their response to therapy, and in some cases, by articular biopsy.20
Many of these soldiers were on a limited pay status, in keeping with the regulations regarding treatment of a venereal disease. Prompt correction of the diagnosis improved the morale of the patient by reinstating his normal pay; it also permitted a realistic prognosis and the institution of proper therapy.
Most physicians were familiar with psychoneurosis as it could manifest itself by symptoms referable to the gastrointestinal tract, the cardiovascular system, et cetera. Apparently, a large proportion of the medical profession was not familiar with psychoneurosis as it affected the locomotor system.
"Psychogenic rheumatism," a musculoskeletal expression of a functional disorder, tension state, or psychoneurosis, was one of the most common causes of generalized or localized aches and pains in muscles and in joints, not only in military life but also in civilian life. It was possible for it to exist alone or it could occur as a functional overlay of a true rheumatic condition, particularly fibrositis or rheumatoid arthritis. Probably the terminology "psychoneurosis manifested by musculoskeletal complaints" would have been more proper than the term "psychogenic rheu-
19Pemberton, R., Buckman, T. E., Foster, G.
L., Robertson, J. W., and Tompkins, E. H.: Studies on Arthritis in the Army Based on 400 Cases. Arch.
Int. Med. 25: 231-282, 335-404, March-April 1920.
matism," or "psychosomatic rheumatism." However, it was found expedient to use the term "psychogenic rheumatism," because of its compactness and its understandability. Many individuals who were inadequate or unable to adapt to military life unconsciously found some solution to their problems by musculoskeletal complaints which were often misinterpreted as "rheumatism" or "arthritis." Those patients did have symptoms, although they were not objective or constitutional, nor could roentgenographic or biochemical manifestations of disease be found. It was most unusual for them to have any real rheumatism, synovitis, arthritis, or organic muscular lesions. On the other hand, if some minor musculoskeletal condition did exist, it was insufficient to account for the severity of the disability. Many times, those patients would have functional complaints referable to other systems as well. The severity of the psychoneurosis could vary from that of a very mild tension state to a major conversion hysteria; not unusual were bizarre gaits, peculiar articular postures and camptocormia (a forward bending of the trunk of the body, often a symptom of some traumatic neurosis), or flexed fingers caused by hysteria.
It is notable that from 16 to 19 percent of the rheumatism patients admitted to the several rheumatism centers had no significant organic rheumatic disease (table 95). A prompt recognition of the presence of "psychogenic rheumatism" soon after the complaint was first made could have gone a long way in reversing this condition before it had become well established by a long period of complaining. This might very well have provided better conservation of manpower, as well as reduction of pension payments after separation from the military service for neuropsychiatric conditions.
Psychogenic Rheumatism Versus Fibrositis
The greatest problem in the differential diagnosis of "psychogenic rheumatism" was with fibrositis. Generally speaking, fibrositis puts its victims at the mercy of alterations in external environment; therefore, weather, heat, cold, humidity, rest, and exercise would influence the condition for better or for worse. In contradistinction, the person with "psychogenic rheumatism" is a victim of his internal environment: the symptoms vary depending upon mood or psyche, pleasure, excitement, mental distraction, worry, or fatigue. The differentiation proved very difficult if a patient had a mild fibrositis with a marked functional overlay.
TREATMENT OF THE RHEUMATIC DISEASES
When the first rheumatism center was established, The Surgeon General, Maj. Gen. Norman T. Kirk, said, "Don't make the center a rheumatism repository." This was outstanding advice, since nothing could
destroy a soldier's potentialities for salvage (his morale, his will to recover and to return to duty) more readily than the atmosphere of a "chronic hospital," or a "rheumatic old soldiers' home." The majority of the personnel admitted to the center had already been hospitalized for prolonged periods of time, evacuated great distances around the world, and in a state of uncertainty. They had no idea whether they would be returned to duty, even limited duty, or whether they would be discharged from the Army. The most immediate question in their minds was what the future might hold for them.
Certainly, for the best interests of the military, as well as the country as a whole, no hasty disposition could be made. It was important, however, that, to develop an estimate of the situation for each patient, a prompt examination of the patient with a definite diagnosis was necessary at the earliest possible moment. The soldier was informed whether a prolonged period of treatment was going to be necessary, whether he would remain in the hospital only a short time, and what the possibilities were for him to return either to military duty or to civilian employment. An overlong hospitalization could easily turn an individual into a soldier with a hospital habit and decrease his salvageability. Even though previously well oriented, he might become a hospital-engendered psychoneurotic with a fixation on illness and a functional overlay that could be more difficult to treat than the original organic condition upon which it was superimposed.
It was a policy, therefore, that immediately upon arrival at the hospital the patient was informed that he could be certain his period of hospitalization would not be indefinite; that after a few days of thorough initial physical examination and study a progressive, well-oriented program of intensive treatment would be initiated; and that, if he had been serving overseas for a prolonged period of time, a furlough would be arranged as soon as possible. Under any circumstances, he would be informed that his intensive treatment, either before or after furlough, would probably continue for 3 to 8 weeks or longer, if necessary, but he would be told the possibilities for reconditioning him to a useful way of life. Every effort was made to maintain a pleasant atmosphere in the hospital and annex which would be conducive to high morale and optimism rather than pessimism.
The comprehensive schemes of treatment used at the rheumatism center for the various rheumatic diseases were those approved by the American Rheumatism Association,21 and used by the leading rheumatologists of the country. Although the rheumatism center did have unusual facilities for physical therapy and hydrotherapy, these facilities were used properly but without undue emphasis and certainly not to the
21Hench, P. S., Bauer, W., Boland, E. W., Dorsan, M. H., Freyberg, R. H., Holbrook, W. P., Key, J. A., Lockie, L. M., and McEwan, C.: Rheumatism and Arthritis; Review of American and English Literature for 1940. Ann. Int. Med. 15: 1002-1108, December 1941.
exclusion of any other useful measure. For the most part, rheumatic patients were gentle, docile, and well behaved. They really asked very little of their physicians; they apparently were aware that no elusive "rapid cures" were available but they did look for a diagnosis and a man-to-man understanding of what they were up against, what they could do for themselves, and what they should do to prevent making themselves worse. This type of patient had very little respect for a physician who tended to brush them off with an incomplete diagnosis or who gave them a fancy diagnosis in medical terms and a "few well chosen words."
To orient these rheumatic patients in the best possible way, a regular rotating series of group consultations or lectures on rheumatism were given in layman's language. There were 12 different lectures. Two or three of them were oriented on general topics for all patients; others were given only to the appropriate group, depending upon the particular disease with which they suffered. Patients with one diagnosis were not admitted to the specific lecture designed for those with a different diagnosis. Very particularly, patients with "psychogenic rheumatism" were not permitted to attend the lectures for patients with rheumatoid arthritis or fibrositis, simply to prevent them from developing misinterpretations of their own conditions. There were special talks designed for this particular group of patients and their needs which were given jointly by rheumatologists and a psychiatrist. Each patient was given a card (fig. 63) with the assignment of the lectures he was to attend.
The lectures were on the following subjects:
1. The meaning of rheumatism and arthritis.
These group lectures were not a substitute for but rather supplemental to individual consultations with ward officers. The lectures were designed to project the individual beyond his period of Army hospitalization and actually into his home and to indicate at least some of the benefits that he might derive from the more formal treatment received in the hospital. They also served as an introduction to the advice which each patient would receive from his home physician. These lectures were
well received and proved to be a great timesaver for the busy medical officers. The recipients of the lectures were encouraged to ask questions at the end of each lecture, particularly on points that bothered them or that they did not understand. They were informed at the time for questions that any question, no matter how trivial it might seem, was a valid question. It was found that these lectures tended to improve morale. Probably, this was because each individual discovered that he was not alone with
his own problem but that others were as bad as or worse than he was and that he had every reason to take courage.
The treatment for peripheral rheumatoid arthritis was quite standard and included, among other things, the removal of obviously infected foci, the providing of highly nutritious diets (but no food fads, "anti-rheumatism vitamins," or specific diets), foreign protein fever therapy in selected cases, simple analgesics, physical therapy, occupational therapy, orthopedic measures to prevent or correct deformities, and gold salts carefully administered to selected patients whose rheumatoid arthritis was progressive despite the use of other more conservative measures. These various measures were blended along with physical reconditioning to restore the best function that could be achieved for each patient.
The characteristic posture of patients with rheumatoid spondylitis dictated the stress that was placed on posture training. It was a highly successful part of the total treatment program, producing correction or near correction of the posture in all but those patients whose spines were ankylosed in an abnormal posture. Probably much of the success of posture training was due to generally successful relief of pain by roentgen therapy.
X-ray therapy appeared to relieve pain and probably halt the progression of the disease. For the purpose of treatment the spine was divided into four areas; namely, (1) the sacroiliac joints and lumbar spine; (2) the lower half of the thoracic spine; (3) the upper half of the thoracic spine; and (4) the cervical spine. A total of 450r to 600r in three or four divided doses was administered to each segment of the spine involved clinically. Treatments were given every other day, with all areas treated within 9 or 10 days. A second course of therapy would be given after an interval of 3 months if symptoms persisted.
All the adjunctive therapy, with the exception of gold therapy, mentioned in the treatment of peripheral rheumatoid arthritis, was also employed in these patients.
Despite the X-ray evidence of osteoarthritis, most of the patients had a moderate to severe secondary fibrositis with muscle atrophy. The treatment program was directed against both conditions.
These patients were given salicylates and heat treatments for the relief of pain. Weight-bearing joints were stabilized by improving muscle strength and orthopedic supports when required. The patients were instructed in ways and means of modifying their living habits to decrease the further wear and tear in the involved joints.
The treatment of osteoarthritis of the cervical spine, in addition to the general treatment already outlined, received intermittent Sayre halter cervical traction and posture training. The traction was very effective in relieving the radicular pain of this type of osteoarthritis.
One of the most important elements in the treatment of either primary or secondary fibrositis was the assurance that this was not a type of arthritis and that it was a self-limited condition with no residual deformity. Salicylates and heat were given for relief of pain. Muscle rehabilitation and posture training exercises were prescribed and carefully supervised.
The treatment of psychogenic rheumatism, although very interesting, posed a most difficult problem, second only in importance to the treatment of rheumatoid arthritis. Although it was a pleasure to be able to reassure soldiers with psychogenic rheumatism that they had no arthritis or muscular rheumatism and that they need not fear that they had a crippling disease, it was always tempered by the difficulty of helping them to develop insight and accept the diagnosis, at least to the point of submitting wholeheartedly to a trial of psychotherapeutic reconditioning. Of course, the latter was much more important than physical reconditioning for this group of patients. Any attempt to use physical reconditioning alone in this type of patient accomplished little or nothing.
Those particular patients were not generally given formal courses of physical therapy or other treatments that would be used for "organic rheumatism," except as diagnostic or therapeutic tests. This was because many treatments of this type tended to fix more firmly in their consciousness the belief that they had a true organic disease.
The acute attacks of gouty arthritis were treated with colchicine. These patients were carefully instructed in the constitution and use of low-purine diets as a means of decreasing the serum uric acid level and to decrease the number of acute attacks. Large doses of aspirin for three
to four successive days each week were administered for the uricosuric effect. Concomitant with the aspirin administration, sufficient sodium bicarbonate was given to maintain the urine in an alkaline state to prevent, as far as possible, the formation of uric acid stones.
Acute gonorrheal arthritis and other specific infectious arthritis were treated with penicillin, followed by rehabilitation. Bursitis and tenosynovitis were treated with heat, rest of the part and splinting if necessary, followed by rehabilitation and restoration of function when possible. Joint tumors, villus synovitis, and joint biopsies were transferred to the orthopedic department for the surgery required.
The task of getting a convalescing soldier physically and mentally prepared to return to military duty is generally spoken of as reconditioning.22
A soldier with rheumatic disease who was considered to be salvageable was "reconditioned" in several steps. He was first reconditioned in the hospital by means of a medical program, followed by a supplemental period of 2 or more weeks during which time he lived in a convalescent barracks and participated in a daily program of physical activity carefully measured to his abilities. Before his transfer to the reconditioning barracks, he was frequently assigned, along with three to five other soldiers with essentially the same needs for reconditioning, to a noncommissioned officer patient who had already transferred to the convalescence barracks or was about to do so, who would periodically gather his squad together and supervise the performance of the reconditioning exercises assigned on the ward.
The ability of these patients to participate in reconditioning and convalescent programs was determined by the ward officer. Some, of course, with transient rheumatic disease could participate in very strenuous programs. Other patients who could only be expected to return to limited service at the most were recommended for less strenuous activities. In every instance, however, an attempt was made to apply the reconditioning program on an individual prescription basis.
If the type of rheumatic condition from which the soldier suffered precluded the possibility of his return to duty within a reasonable period
22Hillman, C. C.: The Reconditioning Program in Army Service Forces Hospitals. Mil. Rev. 24: 10-12, April 1944.
of time, particularly if his disease was essentially progressive and disabling, he would be considered ready for a discharge to civilian life and for subsequent followup treatment by his civilian physician or, if necessary, by a veteran's facility. The Army acknowledged an obligation to a soldier in this category, just as for one who might return to some form of duty. It was necessary to prepare soldiers, not only physically but mentally, to return to a useful civilian life despite the rheumatic disability. This was spoken of as rehabilitation.
Since, after discharge from the Army, the arthritic patient may find it necessary to modify the pattern of his life to a considerable extent to avoid certain factors that might aggravate his disease, it was necessary to instruct him to make only those alterations in his life that were unavoidable but not to the extent of engendering defeatism. The educational program, including the group lectures, and the individual consultations with the ward officers were the chief weapons against the dangers of a wheelchair or crutch psychology. Every attempt was made to have each discharged arthritic patient continue to regard himself as a vital unit of his community. Every effort was made to teach him to live with his disease, not for it. This was the only possible way to make him consider his rheumatism as an avocation rather than a vocation. If he should prematurely or needlessly consider the disease a vocation, then he had taken too long a step toward the sterile existence of the pensioner's rocking chair.
It was the policy of the rheumatism centers to consider patients with rheumatoid arthritis, particularly when it was progressive, as eligible for discharge. However, even many of those patients were salvageable, particularly if they had a good insight into their disease and were only mildly affected.
On the other hand, the disposition of patients with psychogenic rheumatism required even more individual consideration. Many soldiers affected with psychoneurosis of a mild or moderate degree could be expected to render effective service. When, despite conscientious treatment, psychogenic rheumatism persisted to the extent that its victim no longer represented a unit of manpower, there was no other recourse but to recommend him for discharge.
The standing order was "to conserve manpower." The mission of the rheumatism center was to diagnose and treat chronic rheumatic illnesses in an effort to salvage as many men as possible. Despite the most dedicated attempts, only about 45 percent could be returned to some type of duty.
From the time that the rheumatism centers became functional, there was a need for training medical officers in the diagnosis and treatment
of rheumatic diseases. All ward officers had frequent conferences with the chief of the rheumatic disease section to present their findings on all new admissions, to discuss progress of patients receiving therapy, and to plan for dispositions of patients. In addition, there were weekly staff conferences and X-ray conferences to discuss the rheumatic diseases.
The director of the rheumatism center conducted a weekly clinic as a part of the educational program for officers assigned to the section, and for visiting officers, local physicians, and other interested members of the staff.
It was very fortunate that the medical consultant for the Eighth Service Command was an eminent rheumatologist. At the time of his periodic visits, several days were devoted to the presentation and discussion of cases, methods of therapy, ward rounds, and stimulating roundtable discussions.
"It is hoped to make this hospital a source of extensive knowledge on arthritis for the whole medical profession. Studies will be carried on in the use of special drugs, such as sulfonamides and penicillin, in the treatment of arthritis." This is an excerpt from the War Department announcement of the establishment of the first rheumatism center at the Army and Navy General Hospital. It was evident that the Army realized there was an obligation, not only to the soldier with arthritis as an individual, but also as a representative of all human beings with the same problems. The physicians in the various rheumatism centers were encouraged to improve their clinical knowledge and, if possible, the methods of treatment for the benefit of the entire medical profession. A constant effort was made to fulfill these obligations by clinical investigations carried out in all centers. Despite the newness of these centers, they rapidly became the largest rheumatism facilities in the world. They were both treatment centers and supervised schools of rheumatology for physicians assigned temporarily for instruction. They provided a unique opportunity to benefit the rheumatic soldier, his medical officer, the medical profession, and humanity as a whole.
The clinical investigations at the Army and Navy General Hospital during the year 1944 were as follows:
1. Penicillin was found to be ineffective against rheumatoid arthritis.
2. Penicillin was found to be an important adjuvant in the treatment of agranulocytosis resulting from chrysotherapy; that is, as a treatment for the infections which may complicate an agranulocytosis.
3. Studies on the incidence of various types of rheumatic diseases admitted to the facility, as well as pertinent observations on the military aspects of the common rheumatic diseases.
4. Studies on psychogenic rheumatism and its differentiation from fibrositis.23 In the course of this study, differentiation between fibrositis and "psychogenic rheumatism" was developed (table 96).
23Hench, P.S., and Boland, E. W.: Management of Chronic Arthritis and Other Rheumatic Diseases Among Soldiers of the United States Army. Ann. Rheumat. Dis. 5: 106-114, June 1946.
The factors underlying psychogenic rheumatism were determined to be different kinds of fears and frustrations. More specifically they consisted of (1) combat fatigue-less stable soldiers reached the saturation point when the subconscious demand for self-preservation caused the development of musculoskeletal symptoms to save the man's life or his mind; (2) maladjustment to discipline, criticism, or a menial job; (3) lack of privacy caused by military herding; (4) homesickness and loneliness; (5) worry about family finances or illness; (6) worry about lack of promotion; and (7) worry over fidelity of wife, fiancee, or even himself.
Successful treatment was dependent upon the awareness that the soldier had psychogenic rheumatism and that psychiatric treatment was necessary. This type of individual could frequently be salvaged since the result of psychiatric treatment was often most gratifying.
5. Differential diagnosis between post-gonorrheal rheumatoid arthritis and gonorrheal arthritis.
The joint lesion of gonorrheal arthritis was known to be a severe, rapidly destructive infectious arthritis. Without specific therapy to overcome infection, it completed the destruction of the articular cartilage and "burned out" within a period of 3 to 4 months, leaving a useless, often ankylosed, joint. It responded well to penicillin intra-articularly.
Many patients transferred to the Army and Navy General Hospital were seen 3 to 6 months after the onset of the arthritis. Adequate penicillin and sulfonamides, or both, had been administered previously with no benefit to the joint involvement. Instead of the hot, inflamed, excruciatingly painful joint of an acute infection, these patients had a chronic, mild to moderately painful joint or joints. Differentiation of a rheumatoid arthritis precipitated by the acute infection of a venereal gonorrheal arthritis was made by (1) the subsequent course of a chronic rheumatoid-like arthritis often with additional joints becoming involved; (2) therapeutic tests with penicillin when indicated; and (3) biopsies of the joints when indicated.24
6. Further studies on palindromic rheumatism. The clinical characteristics of palindromic rheumatism as first reported25 were confirmed. Various therapies were tried, including purine-free and low-purine diets, coichicine, intravenous and oral calcium preparations, and search for and eradication of foci of infection and febrile reactions with intravenous typhoid vaccine. The last seemed to have a measure of success, but often only of a temporary nature for a few months.
During the year 1945, the investigative program at the Army and Navy General Hospital was more extensive, largely because the rheumatism center was more firmly established; more trained rheumatologists were assigned to the rheumatic disease section; and more medical officer trainees, who were interested in assisting in the various studies, were assigned to the hospital. The clinical investigations for that year were:
1. Cardiac changes occurring in rheumatoid arthritis-a clinical and electrocardiographic study.
2. Further studies on palindromic rheumatism. This investigation was a continuation of the one begun in 1944. Atypical forms of palindromic rheumatism and various types of onsets and clinical courses of the disease were becoming apparent. Some of these patients appeared to have bouts of rheumatoid arthritis which cleared within a few weeks, leaving no residuals. This latter type of arthritis was differentiated into "episodic rheumatoid arthritis."26
24See footnotes 20, p. 496, and 23, p. 506.
The studies of palindromic rheumatism and the failures of the various forms of treatment, as well as the gradual development of a chronic rheumatoid arthritis in some cases, raised the question as to whether it might not be an atypical form of rheumatoid arthritis. These impressions led to a trial of gold therapy in these patients.27 Three patients were treated with a favorable response to gold thioglucose.
3. The diamidines in the treatment of rheumatoid arthritis.
4. The clinical and pathologic features of psoriatic arthritis and psoriatic arthropathy.
5. Rheumatoid spondylitis-a study of 100 cases with special reference to diagnostic criteria.28 This was a study as a followup to one done at Hoff General Hospital, Santa Barbara, Calif. The purpose of this study was to determine early diagnostic criteria for the disease. Patients with unequivocal evidence of the disease were included. Each patient was questioned in detail in order to determine the symptoms which occurred prior to the finding of definite spinal involvement. It was determined that the onset was insidious. By a correlation of the symptoms as the disease progressed, with X-rays, it was determined that the earliest roentgenographic changes appeared in the sacroiliac. It was recommended that rheumatoid spondylitis should be suspected in young men with recurrent or persistent low back aching and stiffness, and that the sacroiliac joints should be examined for the characteristic changes which they had found of a bilateral sacro-illiitis.
6. Rheumatoid spondylitis-correlation of clinical and roentgenographic features.29 A group of 50 soldiers with definite X-ray evidence of rheumatoid spondylitis were studied. In two-thirds of these patients, the clinical findings were advanced to a greater degree than the roentgenographic changes. Attempts were made to find explanations for all the symptoms in relation to the extent of involvement. Since clinical involvement was at least one or two spinal segments higher than the roentgenographic evidence, if X-ray therapy was to be administered it should be chosen on the basis of the clinical involvement.
7. The cerebrospinal fluid in rheumatoid spondylitis.30 Since rheumatoid spondylitis must be differentiated from other causes of chronic low back disability, this study was undertaken to determine whether biochemical studies of cerebrospinal fluid might afford data upon which clear and early differentiations could be made.
27Boland, E. W., and Headley, N. E.: Treatment of So-Called
Palindromic Rheumatism With Gold Compounds. Ann. Rheumat. Dis. 8: 64-69, March
Moderate increases in protein content of the spinal fluid were found in patients with rheumatoid spondylitis. The increase was due largely to the severity of the disease rather than the duration. The elevation of spinal fluid protein was found to be of little value in differentiating rheumatoid spondylitis from other spinal conditions. When, however, the protein content was elevated above 100 mg. per 100 cc., some other cause should be sought, even though spondylitis was also present.
8. The use of penicillin in the treatment of agranulocytosis-report of a study resulting from chrysotherapy in rheumatoid arthritis.
9. The management of chronic arthritis and other rheumatic diseases among soldiers in the U.S. Army.
10. Precipitating and predisposing factors in rheumatoid arthritis among soldiers.
11. The incidence of rheumatic diseases among soldiers-a study of 6,000 cases at an Army rheumatism center.
12. Roentgen therapy in the treatment of rheumatoid spondylitis.31 Although roentgen therapy had been administered for rheumatoid spondylitis, there was considerable doubt about its efficacy. This study was designed as a blind triple crossover to determine the benefit of X-ray therapy. Twenty-five patients received roentgen therapy to the area (one or more courses) of the spine clinically involved over a period of 6 months. A second group of 25 patients were exposed to the roentgen therapy equipment but no roentgen rays on one or more occasions for 6 months. The third group of 25 received physical therapy. All received salicylates as needed. Between the sixth and the ninth months, the groups were crossed over. At the end of 9 months, all had received one or more courses of 600r to each area of the spine clinically involved; many had had a "psychic" X-ray treatment; and all had been given physical therapy, particularly posture training. There was a 92-percent response to the roentgen therapy.32
13. Post-gonorrheal rheumatoid arthritis.
Ashburn General Hospital functioned as a rheumatism center for 15 months and 18 days, beginning on 1 September 1944. It was declared surplus on 12 December 1945. All patients were disposed of by 18 December 1945.
The officers assigned to the section on rheumatic diseases had very fine opportunities to study these conditions in all their manifestations. Despite the limited time this center was in operation, various types of research in rheumatic diseases were carried out:
31(1) Smith, R. T., Boland, E. W., Shebesta, E. M., and
Hench, P. S.: Roentgen Therapy in the Treatment of Rheumatoid Spondylitis. Presented at American
Rheumatism Association Annual Meeting, New York City, June 1946. (2) Boland, E. W.: Medical
Progress: Rheumatoid Spondylitis; Its General Features and Management. California Med. 65: 285-292,
1. Arthritis resembling Reiter's syndrome.33
2. The penetration of penicillin into joint fluid following intramuscular administration.34
3. The effect of Prostigmine (neostigmine) on the muscle spasm in rheumatoid arthritis.35
4. The diagnosis and treatment of Reiter's syndrome.36
5. Gold therapy in the treatment of rheumatoid arthritis. Only 21 patients were considered suitable for gold therapy before the investigation was summarily terminated by the closure of the center.
Although chrysotherapy enjoyed a measure of popularity in civilian medical circles, it had not been an approved method of treatment in the rheumatism centers. Approval was lacking because of (1) the prolonged period of weekly injections required (up to 24 or more) ; (2) the general belief that gold was highly toxic; and (3) the lack of definite evidence to show that gold was capable of producing remissions of the disease.
The possible benefits which might be achieved with gold therapy in 1945 were severely limited by the fear of the severe toxic effects of agranulocytosis, exfoliative dermatitis, and renal damage, particularly since there was no known antidote for gold. Consequently, treatment programs were arbitrarily limited to 20 to 24 weekly injections; to an overall total dosage of 800 to 1,000 mg. of the drug; or were administered in courses with rest periods without gold following each remission. These limitations produced an unspectacular remission rate of approximately 35 percent.
The discovery of the dramatic changes that could be produced in rheumatoid arthritis by ACTH and cortisone and its derivatives directed the attention of many rheumatologists from chrysotherapy. On the other hand, the beneficial effect of the adrenocorticosteroids in the treatment of gold toxicity encouraged others. With the further revelation that BAL (British anti-lewisite)37 was a specific antidote for gold toxicity, much of the stigma attached to gold was removed.
Investigators, no longer hampered by the arbitrary limiting of gold to a dose that produced the least toxicity in the greatest number of patients, began to increase the remission rate to as high as 65 percent by more prolonged treatment. They also eliminated the rest periods from
33Hollander, J. L., Fogarty, C. W., Jr., Abrams, N. R., and
Kydd, D. M.: Arthritis Resembling Reiter's
Syndrome; Observations on 25 Cases. J.A.M.A. 129: 593-595, 27 Oct. 1945.
gold and prolonged the remissions by giving a maintenance at 2- to 4-week intervals for months to years.38
Of the more than 500,000 patients with rheumatic diseases admitted to hospitals between the years 1942-45, less than 20,000 of them were transferred to the arthritis centers at the Army and Navy General Hospital and Ashburn General Hospital. As had been recommended originally, not all patients were to be sent to the centers because those with acute and short-lived situations could be treated locally. Only those with the possibility of a need for prolonged treatment or diagnostic problems were considered eligible for admission to these hospitals. Even among those patients who were considered to be poor risks, approximately 45 percent could be returned to some type of military duty. The need for rheumatism centers has been well established from the experience in World War II.
It is conceivable that a greater conservation of manpower would be possible among military personnel with rheumatic diseases. Specific diagnosis at an earlier hospitalization could permit effective treatment and decrease the need for evacuation to the Zone of Interior. This would be particularly true of the second most common rheumatic condition, psychogenic rheumatism. Immediate recognition would permit adequate psychiatric therapy to prevent this conversion state from becoming a fixed disability.
Provision should be made in all theaters of operations to have at least one officer, trained in the care of rheumatic diseases, on the medical staff of each hospital facility. He would be responsible for making a prompt diagnosis, initiating therapy in all patients, and determining whether they could be treated there and returned to duty or would require more prolonged treatment and should, therefore, be evacuated.
Special rheumatic disease centers should also be available for the care of chronic rheumatic diseases and to handle diagnostic problems. Conservation of military manpower should continue to be an important consideration in these centers. An additional responsibility should be assigned; namely, conservation of civilian manpower for those patients where there is no possibility of further military duty. These centers should be staffed as fully as possible with well-trained rheumatologists, employing the latest refinements in the treatment of rheumatic diseases. Even more emphasis should be placed on clinical investigations which, carried out in the largest facilities of their type in the world, under the supervision of the top experts in our Nation, could lead to greater conservation of manpower.
38Finally, in 1958, a remission rate of 82 percent was achieved by gradually increasing the weekly doses of gold in those patients who failed to respond to 50 mg per week for 12 weeks. See Smith, R. T., Peak, W. P., Kron, K. M., Hermann I. F., DelToro, R. A., and Goldman, M.: Increasing the Effectiveness of Gold Therapy in Rheumatoid Arthritis. J.A.M.A. 167: 1197-1204, 5 July 1958.