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 forwhich historical data are available, although it attracted little attentionbefore World War II. Enteric infection and malaria in earlier wars, andinfluenza and its complications in World War I, overshadowed all other acutediseases. Inadequate diagnosis also prevented the recognition of the militaryimportance of this disorder.
The recorded experience of the U.S. Army in the American Civil War1 revealsthat acute rheumatism occurred with remarkable frequency. In 5.2 years, 146,000 caseswere reported among white troops at a rate of 61 per1,000 per annum. Certainly, not all of these were acute rheumatic fever, butexamination of the case records that have been preserved in the history of thatwar indicates that a substantial number of them was certainly this disease. Thisimpression is confirmed by 642 deathscaused by rheumatism, endocarditis, and pericarditis. Furthermore, the diseaseoccurred principally in the winter among fresh levies of troops, anepidemiological pattern which resembles that of rheumatic fever during World WarII. In retrospect, it is impossible to define the magnitude of the problem ofrheumatic fever in the Civil War, but it must have been great.
The situation during World War I was similar.2 There were24,770 admissions for acute articular rheumatism reported, butthe significance of this disease was apparently overlooked even though it wasoccurring at the rate of 6.00 per1,000 per annum. The fact that many of these cases were rheumatic fever was notappreciated, and this disease is not mentioned by name in the official historyof the Medical Department in World War I. The disease occurred with greatestfrequency in the same areas as it did during World War II but at substantiallyhigher rates.
In spite of this background and of the great advances thathad been made in the period between the wars in knowledge of the pathogenesisand natural history of the disease, the U.S. Army Medical Department was poorlyequipped to cope with the problem of rheumatic fever in the first years of WorldWar 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 theimportance of rheumatic fever as a military problem. Rheumatic
1Medical and Surgical History of the War of theRebellion. Medical History. Washington: Government Printing Office, 1870, pt. I,vol. 1, pp. 637-639.
2The Medical Department of the United States Army inthe 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 onthe weekly statistical summary until December 19413and was often incorrectly diagnosed during the following 2? years.
Of equal importance was the failure to appreciate the intimate relationshipbetween infection by group A hemolytic streptococci and rheumatic fever. Medicalofficers in the field were not trained to distinguish streptococcal fromnonbacterial respiratory disease, so that the hemolytic streptococcus was onlyrecognized during the period 1940-43 as a common cause of illness in those few camps wherescarlet fever was occurring frequently. The importance of the case without arash was not realized. Lastly, the Army and its consultants had not familiarizedthemselves with available civilian and military data which would have made itpossible to predict with considerable accuracy those geographic areas in whichoutbreaks of hemolytic streptococcal infection and rheumatic fever might beexpected.
Little information is available as to the situation during the prewarexpansion of the Armed Forces. During 1941, outbreaks of scarlet fever followed by rheumatic feveroccurred 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, andM. Henry Dawson, of the Commission on Hemolytic Streptococcal Infections, ArmyEpidemiological Board (Board for the Investigation and Control of Influenza andOther Epidemic Diseases in the Army), visited each of these camps in November 1941.They noted that medical officers did not recognize theassociation of scarlet fever and streptococcal disease occurring without a rashnor did they connect either of them with rheumatic fever.4
The available records do not reveal that streptococcal disease was viewedwith alarm during the period 1941-42, although the incidence of scarlet fever, in the totalArmy, during those years was comparable to that in 1943-44 when interest in infection by these organisms was verygreat. This was the result of the mildness of the acute streptococcal diseaseand of the failure to report accurately the occurrence of rheumatic fever priorto 1943.
The first detailed information in regard to the problem ofrheumatic fever was obtained early in February 1943 when a survey of the continuing scarlet fever epidemic atFort Francis E. Warren, Wyo., revealed that more than 100 patients with thisdisease had been hospitalized but neither correctly diagnosed nor reported toThe Surgeon General.5 Subsequently, the rapid increase in size ofinstallations 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 EpidemiologicalBoard, 24 Nov. 1941, subject: Report on Reconnaissance Trip to the Fifth andSixth 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 EpidemiologicalBoard, 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 FortFrancis E. Warren.
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ease in Colorado and Utah was associated with epidemics of streptococcalinfection and rheumatic fever. Additional surveys were made which againdelineated the deficiencies in background and information on the part of medicalofficers in regard to streptococcal respiratory disease and its complications,although no control measures were recommended.6
During 1943, 6,710 admissions forrheumatic fever were reported from the Army in the United States. According tosummaries of the statistical health reports, about 74 percentof 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 seriousdisease requiring prolonged hospital care and resulting in many separations fromservice attracted a very considerable interest in the offices of The SurgeonGeneral of the Army and of the Air Surgeon. Three programs designed to acquirenew knowledge about hemolytic streptococcal disease with special reference toits relationship to rheumatic fever and to control methods were institutedtoward the end of 1943. All wereconducted in the field with the active assistance and cooperation of manycommand and medical officers.
One of these programs was under the auspices of the Commission on HemolyticStreptococcal Infections. Its purpose was the careful investigation of a largenumber of cases of hemolytic streptococcal respiratory infection for the purpose of defining the natural history, bacteriology, andimmunology of these disorders. Associated with this group was the Commission onAir-Borne Infections, Army Epidemiological Board, whose main interest lay in theinvestigation of methods for control of airborne infection with particularreference to the hemolytic streptococcus. The results of these two Commissionprojects are described elsewhere.7 The third was the Army Air Forces RheumaticFever Control Program, Office of the Air Surgeon, which will be the subject of alater section of this chapter. These three programs were in active operationthroughout 1944. Much new knowledgewas acquired, but effective methods for the control of streptococcal disease andrheumatic fever were not forthcoming.
The Air Forces investigated intensively the role ofsulfonamide prophylaxis during the early months of 1944. Streptococcalinfection and rheumatic fever were notably reduced, and the use of thistechnique in certain defined situations, primarily for the prevention of thesediseases, 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 highlyresistant to sulfonamides had emerged and were causing
6Report, Chester S. Keefer, M.D.,Director, and Lowell A. Rantz, M.D., Member, Commission on HemolyticStreptococcal 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 onAir-Borne Infections, Army Epidemiological Board, 1941-45. [Official record.](2) Commission on Hemolytic Streptococcal Infections, Army EpidemiologicalBoard. [Undated.] [Official record.]
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disease among naval personnel where chemoprophylaxis had been widely used ona mass basis since December 1943.
Streptococcal infection continued to be epidemic throughout 1944, and 4,877 casesof rheumatic fever were reported in the United States. The highest incidence wasagain in the Sixth and Seventh Service Commands where 37 percentof 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 amongtroops abroad for the first time in 1944 when 1,805 cases of the latter diseasewere reported. This represented a rate of only 0.47 per1,000 per annum or approximately 38 percentof 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 preventionof streptococcal infection and rheumatic fever, was no longer effective. Diseasecaused by resistant streptococci was epidemic in the U.S. Navy, and an outbreakof infection caused by similar strains had occurred at an Army Air Forcesstation. The entire problem was considered at a National Research Councilconference on 28 February 1945. The failure of sulfonamide prophylaxis was detailed, andthe hazards involved in its continued use were described. As a result of theseexperiences in the Navy, this technique was applied only selectively in the ArmyAir Forces and practically not at all in the Army Ground Forces. The possiblevalue of penicillin prophylaxis was explored at another National ResearchCouncil conference on 20 March 1945, and studies for its evaluation under field conditions bythe Army Air Forces were outlined but not undertaken.
The incidence of scarlet fever and rheumatic fever in theArmy in the United States decreased in 1945 inspite of the absence of effective control measures. The incidence ofstreptococcal sore throat rose from 0.82 per1,000 in 1944 to 3.64in 1945. The effect was an increase in rate for the threeconditions combined, from 3.98 per1,000 in 1944 to 5.21 in 1945. Only 1,675 cases of rheumatic fever were reported. Two thousand andfifty additional cases occurred in the Army overseas. Another important NationalResearch Council conference on streptococcal disease was held on 7July 1945. The war ended in the autumn of that year, andinformation on the occurrence of this disease and rheumatic fever duringdemobilization is not available.
EPIDEMIOLOGY AND STATISTICS
Statistical and epidemiological data in regard to rheumaticfever and the causative hemolytic streptococcal infection has been presented indetail in another volume in the history of the Medical Department in World WarII.8
8MedicalDepartment, United States Army. Preventive Medicine in World War II. Volume IV.Communicable Diseases Transmitted Chiefly Through Respiratory and AlimentaryTracts. Washington: U.S. Government Printing Office,1958.
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This information will not be recapitulated, but a summary isappropriate. Of about 18,000 reported cases of rheumatic fever, 34 percent developedin troops stationed in theSeventh Service Command at a rate about six times the rate for the total Army.Hemolytic streptococcal respiratory disease was epidemic in all of the highincidence areas for rheumatic fever, and a direct relationship between infectionby these organisms and the rheumatic state was established by criticalinvestigations.
Approximately 23 percentof all rheumatic fever admissions occurred in troops overseas. The rate wasabout two-fifths of that in the continental United States. In terms of rates,the worst experiences were encountered in the European, Mediterranean, andMiddle East theaters. Three reports describing the disease as it occurred in theNorth African, Mediterranean, and European theaters have been published.9The problem was much less in the China-Burma-India theater and in the Pacificand Latin American areas.
Rheumatic fever was most common in the months of Januarythrough 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 feveras it occurred among troops has been well defined in a few publications,10and in much greater detail in reports of the activities of Army and Air Forcerheumatic fever centers.11 These three reports, describing the disease as itwas seen at Birmingham General Hospital, Van Nuys, Calif., Foster GeneralHospital, Jackson, Miss., and Torney General Hospital, Palm Springs, Calif., aremost
9(1) Bland, E. F.: Rheumatic Fever andRheumatic Heart Disease in the North African and Mediterranean Theater ofOperations, United States Army. Am. Heart J. 32: 545-559, November 1946. (2)Claiborne, T. S.: Rheumatic Fever and Rheumatic Heart Disease in a GeneralHospital in North Africa. Med. Bull. North African Theat. Op. (No. 5) 1: 8, May1944. (3) Foster, R. F.: Rheumatic Fever Here and in the European Theater ofOperations. 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 aLarge Station Hospital. M. Clin. North America 28: 124-147, January 1944. (2)Wright, I. S.: Experiences With Rheumatic Fever in the Army. Bull. New YorkAcad. Med. 21: 419-432, August 1945. (3) Connor, C. A. R.: Experiences WithRheumatic 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 toMarch 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, RheumaticFever Section, Birmingham General Hospital, to The Surgeon General, attention:Director, Medical Consultants Division, 30 Nov. 1945, subject: Report on Studieson Rheumatic Fever. (2) Report, Capt. John F. McGinty, MC, Chief, RheumaticFever Section, Foster General Hospital, to The Surgeon General, attention:Director, Medical Consultants Division, 14 Dec. 1945, subject: Report on theActivities 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 GeneralHospital, to The Surgeon General, attention: Col. Arden Freer, MC, Director,Medical Consultants Division, 11 Mar. 1946, subject: Report of Activities ofTorney 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 andthat the acute phases of the illness were not observed by the officers preparingthese reports. The information about the early stages of the illness werecompiled from abstracts of the station hospital records which accompanied thepatients. These were usually quite complete. Examination of other reports, andthe extensive experience of the author in the field during this period,indicates that table 33 and the commentary which is to follow presents anaccurate picture of rheumatic fever as it occurred during World War II in theArmy.
[Percent expressed as percentages of cases in which the respectivemanifestations 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 |
|
| 262 | 807 | 401 |
1Not recorded.
Striking differences between the rates of occurrence ofvarious clinical manifestations, notably those referable to the heart, reflectdifferences in interpretation of physical and laboratory signs by medicalofficers in the various hospitals. Rheumatic fever in the Army was an arthriticdisease. Almost 100 percent of cases exhibited subjective or objective evidenceof joint involvement. This simply means that the nonarthritic form of the
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disorder was rarely recognized. Detailed studies beginningwith the initiating streptococcal infection revealed a considerable number ofcases in this category.12
A past history of rheumatic fever was obtained in 40 to 50 percentof all cases. This demonstrates that persons who have had rheumatic fever aremuch more likely to develop another attack after streptococcal infection thanare nonrheumatics. A preceding upper respiratory infection, sore throat, orscarlet fever had been recognized by about half of the patients. Nearly allhospitalized patients had fever and malaise in addition to arthritis, but manyother clinical manifestations of rheumatic fever were uncommon. Epistasis,erythematous skin lesions, pericarditis, pneumonia, and subcutaneous nodulesoccurred infrequently, although very often more than one of these signs ofsevere rheumatic fever was demonstrated in the same patient.
Evidence of carditis was obtained frequently. During the acute phase of theillness, the most common sign was an abnormal electrocardiogram. Prolonged AV(atrioventricular) conduction was demonstrated in about one-quarter of allpatients and unequivocal T-wave abnormalities in an additional 3 to 14 percent. The average percentage for all patients wasapproximately 7 percent. Other abnormalities were reported by two of thesehospitals to bring the total presenting electrocardiographic evidence ofcarditis 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 ofshort duration. Only three deaths from active rheumatic fever with heart failureare recorded.
Cardiac murmurs were heard frequently, but the significance of many isdifficult to assess. Apical systolic murmurs were discovered in 45 percent of cases in one hospital but in only about 12percent in the other two. Apical diastolic murmurs were uncommon. Evidence ofaortic 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 ofrheumatic fever under study. This was undoubtedly so in some, but the authorexamined a number of men in whom valvular disease was present at the onset ofthe attack and was a residuum of a previous rheumatic episode. Thecharacteristic murmurs had been overlooked at the time of induction into theArmy. The available data, obtained at convalescent centers, do not permit readydifferentiation 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 beindicative of its presence.
12Rantz, L. A., Boisvert, P. J., and Spink, W. W.: Hemolytic Streptococcic Sore Throat; ThePoststreptococcic 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 rheumaticfever in the Army is not available. Prior to the autumn of 1944, thesepatients were treated in station hospitals until convalescence was sufficiently established to permit return to duty, separation from service, ortransfer to a regional general hospital. During this early period, treatment wasthe responsibility of the chief of medicine in each station hospital, and variedgreatly from one to another.
Great interest had been aroused at about this time in the use of very largeamounts of salicylates in the treatment of rheumatic fever. Regimens were widelyemployed in which every effort was made to administer 10 gm. per day of sodiumsalicylate. The drug was not often given intravenously in the Army, butsignificant toxicity was frequently encountered.
The other important phase of the treatment of rheumatic fever involved restand this was regularly utilized but in widely differing degrees. Strict bed restover long periods of time and until all clinical and laboratory signs ofactivity had vanished was usual. Often, fantastic limitations of activity wereimposed, and patients were forbidden to feed, wash, or shave themselves for manyweeks. As late as 1944, War Department Technical Bulletin (TB MED) 97, dated 29September, warned that the head of the bed should not be raised during theperiod of active disease, since absolute recumbency was believed to be animportant phase of treatment. No chemoprophylaxis of streptococcal infectionswas undertaken before 1944.
The response to rest and the administration of salicylates in these patientswas almost always excellent. Fever and arthritis regularly melted away so thatthe patients ordinarily felt very well within 2 to 3 weeks, and restrictions tobed became difficult. More prolonged and difficult illnesses did occur,particularly in the presence of pericarditis, but such cases accounted for lessthan 5 percent of the total. Heart failure was virtually unknown and itsmanagement was not a significant problem. Only 1 death due to rheumatic feverwith heart failure occurred in 1,470 cases admitted to convalescent centers(table 33). The only data in regard to the duration of laboratory evidence ofactivity are from the Torney General Hospital experience. The erythrocytesedimentation rate (Wintrobe) became normal in an average of 11.2 weeks. It waselevated for more than 4 weeks in 59 percent and for more than 9 weeks in 34percent of 401 cases. Abnormal rates persisted for more than 5 months in only 12percent.
Treatment of early rheumatic fever was doubtless much betterstandardized after September 1944 when TB MED 97 was published. This directiverecommended about 1 month of bed rest at the station hospital followed bytransfer to a convalescent center by air. Sodium salicylate was to be given in adose of 16 gm. during the first 24 hours, followed by 10 gm. per day. High bloodlevels of the drug were doubtless attained, but toxicity
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must have been commonplace with this regimen. Continuous prophylaxis withdaily administration of a sulfonamide was directed.
The usual treatment of rheumatic fever with prolonged andoften absolute bed rest until clinical and laboratory evidence of quiescencewas obtained produced results which were not entirely satisfactory becausecardiac neurosis was a frequent complication. One group working at an Air Forcecenter13 utilized early ambulation in the treatment of 100 patients,continuing the administration of salicylates. The results were impressive inthat the disease process subsided in the expected time without any increase inthe incidence of chronic valvular heart disease. The experience of the authorand his associates was similar in unpublished studies of a smaller group ofpatients.
LATE TREATMENT AND RESULTS
It was not until the middle of 1944 thatmuch information became available in regard to the course of rheumatic fever inpatients 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 hadbecome quiescent, or forwarded to a general hospital. In the experience of theauthor, the first two events usually took place after about 6 months oftreatment. Transfer to a general hospital was reserved for the very few patientswhose disease was not ameliorated promptly or in whom the diagnosis was indoubt.
In Army Air Forces Letter 25-7, dated 29 April 1944, the Army Air Forces designated seven regional hospitals asrheumatic 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 AirField, Nev.; Hammer Field, Calif., and Santa Ana Army Air Base, Calif. InSeptember 1944, the Army ServiceForces followed suit and Birmingham, Torney, and Foster General Hospitals wereso designated. All of these were in the southern part of the United States. Thedirectives stated that patients were to be treated for about 1 month by bed restand heavy salicylate therapy at the station hospital. At this time, it wasanticipated that the acute manifestations of the disease would have subsided,and the patient was to be transferred by air to the center for additional restand eventual rehabilitation. The number of available ambulance planes was notgreat, and it is not known how often this technique was employed. In the absenceof air transport, patients were to be kept at the station hospital until fullyconvalescent and able to travel by train.14
13Robertson, H. F., Schmidt, R. E., andFeiring, W.: The Therapeutic Value of Early PhysicalActivity in Rheumatic Fever. News Letter, Army Air Forces Rheumatic FeverControl Program, vol. 2, No. 10, p. 17, October 1945.
14Army Service Forces Circular No.360, 1 Nov. 1944.
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Very complete statements about the operations of the general hospital centershave been preserved,15 and the following important facts aboutthelate effects of rheumatic fever in troops have been obtained from them inaddition to those that were used earlier in describing the nature of the acuteillness.
Complete recovery without residua was the rule in these casesof rheumatic fever in young adults. Chronic valvular heart disease was the mostserious complication. Table 33 shows that aortic insufficiency was demonstratedin from 5.0 to 10.3 percent; mitral stenosis in 2.5 to 8.4 percent; and mitralinsufficiency in from 11.8 to 45.0 percent of all cases. Three difficultiesarise in interpreting these data. One pertains to the varying diagnosticcriteria that were applied, particularly in the recognition of mitralinsufficiency. It is evident that these criteria were difficult to establish.They were less rigorous at Torney General Hospital than at the other twocenters. A second stems from the fact that medical officers at the centersattributed all of the valvular disease present at the time of dismissal from thehospital to the current episode of rheumatic fever. There were many instances,as already indicated, when significant murmurs were present at the onset of theillness. These were certainly the result of previous attacks, the signs havingbeen missed during the induction physical examination. No satisfactory datapermitting detailed analysis of this important point are available. A thirddifficulty arises from the fact that the period of followup was short since itis known that clinical evidence of rheumatic valvular heart disease appearsslowly and irregularly after an acute rheumatic episode.
One excellent study of 135 patients16hasprovided valuable information as to the outcome after a period of observation of4 to 8 years. Followup physical examinations revealed no abnormalities in 75.4percent. An additional 16, or 11.8 percent, had only an apical systolicmurmur, 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 only12.8 percent of these patients. It has been suggested that not all of theselesions were the result of the rheumatic fever which occurred during militaryservice. Only three of the entire group had definite enlargement of the heartand none showed evidence of cardiac insufficiency. The signs described above hadbeen present at the termination of the rheumatic attack in all but one case.Thus, there had been an extraordinarily low incidence of progression of heartdisease 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, orneurocirculatory asthenia, as evidenced by precordial pain, dyspnea, andpalpitation was
15See footnote 11, p. 229.
16Engleman, E. P., Hollister, L. E., and Kolb, F. O.: Sequelae ofRheumatic Fever in Men; Four to Eight-Year Follow-Up Study. J.A.M.A. 155:1134-1140, 24 July 1954.
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present in one-third of these patients. Anxiety neurosis wasa more common complication of rheumatic fever in these individuals than valvularheart disease. Only a few of the study group described were disabled and nearlyall were in school or were employed.
It is generally believed that clinical recovery fromrheumatic fever is accompanied by complete disappearance of pain in thejoints. It is of great interest that this was not so in the Army. Persistentarthralgia was commonplace, having been noted in 50 to 60 percent of the casesand having continued for as long as 6 years.17 Physical and roentgen examinationof the joints never revealed any abnormalities after the first few weeks of theillness during which time effective salicylate therapy was instituted. Theresidual pain was often very disturbing to the affected individuals andinterfered with resumption of their normal activity.
RECONDITIONING
Formal programs for the reconditioning of convalescent casesof rheumatic fever were not introduced in the Army until 1944 when treatmentcenters were established. Before this time, the station hospitals in areas wherethe disease was common were completely lacking in facilities for this purpose.Neither space, personnel, nor a suitable climate were available. This seriouslack was an important contributing factor which led to the frequent appearanceof cardiac neurosis. After the Army Service Forces and the Army Air Forcesestablished centers, the situation improved greatly. Men were moved to theseestablishments fairly early in the disease, usually during the second or thirdmonth of illness.
Each of the centers located in general hospitals developed an elaborateprogram of supervised, graded, and gradually increased activity for convalescentpatients. The official reports speak in glowing terms of the efficiency ofthese techniques. Complete recovery was hastened and cardiac neurosis minimized.18Reconditioning was also an important aspect of the treatment at the Army AirForces rheumatic fever centers,19but information about results was not preserved. A formal study of the problemwhich was conducted in the physical fitness laboratory at Randolph Field, Tex.,demonstrated that early activity proved to be safe and beneficial whenaccomplished 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 AirForces Rheumatic Fever Control Program, vol. 2, No. 2, pp. 17-21, February 1945.
18See footnote 11, p. 229.
19Ershler, I.: Convalescent Programfor Rheumatic Fever. News Letter, Army Air Forces Rheumatic Fever ControlProgram, vol. 2, No. 1, p. 1, January 1945.
20(1) Karpovich, P. V.: Physical Reconditioning of Rheumatic Fever Patients. News Letter, Army AirForces 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., andWeiss, R. A.: Physical Conditioning After Rheumatic Fever. [Official record.]
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DISPOSITION
The problem of disposition of patients who had had rheumatic fever was aknotty one during the early years of World War II, and formal guidance was notprovided by The Surgeon General. Each hospital made its own policy based on theexperience of its medical officers. In general, men were retained in serviceafter recovery if there was no evident residual cardiac damage. Often, theseverity of initial illness was also considered. Some hospitals were separatingall men in whom the diagnosis of rheumatic fever was made because it wasbelieved that the chance of recurrence was too great if these individuals wereretained in the service. An attempt was made to make the policy more uniform bythe publication of Circular Letter No. 144 bythe Office of the Surgeon General on 7 August 1943. Discharge was recommended forall men with residual cardiac damage and retention in service of all others whohad fully recovered. This policy, in the experience of the author, was notclosely followed by officers in the field who frequently tailored it to fitindividual cases.
Army Air Forces Letter 25-7 definedthe disposition of rheumatic fever patients in the Army Air Forces and statedthat those who had made a complete recovery without residua should be returnedto full duty. Those with evidence of cardiac damage were to be discharged unlessthey possessed special skills in which case they could be retained in theservice and marked for limited duty. Various special situations were alsoconsidered in detail. Data on disposition of 410 casesof 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 continuingfor more than 3 months. Only 23 percentwere separated from service because of residual cardiac changes. This was lessthan 10 percent of the whole treatment group. No comparable directives from theArmy Service Forces have come to the attention of the author, and it is ofinterest 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 threegeneral hospitals which served as rheumatic fever treatment centers.21 AtBirmingham General Hospital, the advice given in Circular Letter No. 144 was followed until September of1945, and approximately 50 percentof the patients were discharged, the remainder being returned to limited duty.After that date, any evidence of carditis was accepted as grounds forseparation. This included more than 80 percent of all cases. The staff at FosterGeneral Hospital formulated its own policy and discharged all patients withmultiple 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 receivedcertificates of disability for discharge. The medical officer in charge of therheumatic fever center at Torney General Hospital believed that troops who hadhad rheumatic fever were unsuitable for further military service because of thegreat risk of recurrence. He arbitrarily recommended 80 percent of them fordischarge.
In retrospect, it is difficult to understand why a uniform policy fordisposition of rheumatic fever patients was not established for the Army ServiceForces hospitals by The Surgeon General. The varying criteria for dischargefrom the service were unfair to the patients and created a sense of frustrationand insecurity among the responsible medical officers who were constantly indoubt as to the proper course to follow.
CONTROL
Rheumatic fever control programs were not undertaken by theArmy Service Forces, although intensive research was carried out by thecommissions 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 afull-scale rheumatic fever control program under direct authority from theCommanding General, Army Air Forces, in the fall of 1943. Its objectives22were (1) recommendations for the use of sulfonamide prophylaxis for thecontrol of respiratory infections and rheumatic fever, (2) adoption of uniformstandards for the diagnosis of rheumatic fever, (3) coordination andstandardization of bacteriological techniques in the study of the hemolytic Streptococcus, (4) establishment of a uniform convalescent program and followupstudies on positive and suspected cases of rheumatic fever, and (5)consideration of special projects and investigations at various Army Air Forcesposts.
All of these goals were accomplished with varying degrees of success. Thegreatest activity was in the area of study and control of streptococcalinfection under objectives 1, 3, and 5. This work has been described in detailelsewhere.23 Uniformity of diagnosis and treatment was accomplishedpartly by educational activities directed toward the staffs of stationhospitals, but more directly by the creation of centers for the care of patientswith rheumatic fever and the use of air transport permitting transfer to theseinstitutions at an early stage of the disease. Much was accomplished by the widedistribution 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 FeverControl 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 tothe advisability of refusing induction to individuals with a past history ofrheumatic fever because the number of such persons who developed recurrences ofthe disease was high. Mobilization Regulations No. 1-9 was variously modified.Between August 1940 and April 1944, active acute rheumatic fever or verifiedrecurrent attacks of the disease in the past placed a man in the unacceptablegroup. The latter history was clearly not sought adequately by examiningphysicians at induction stations. In April 1944, the order was changed toinclude active acute rheumatic fever and verified single or recurrent attackswithin 2 years. This order was not well designed since a definite attack ofrheumatic fever has the same significance at any time in the life of theindividual.24
RESEARCH
Clinical investigation of many phases of rheumatic fever was undertaken atnumerous hospitals. The large amount of clinical material available to manyhighly skilled investigators permitted the rapid accumulation of information inregard to diagnosis, course, and treatment. Many reports of these studies werepublished but will not be reviewed here. The lack of special facilities ininstallations other than those specially supported by the Army Air ForcesRheumatic Fever Control Program or by the commissions of the ArmyEpidemiological Board prevented, for the most part, any fundamental work bythese groups.
SUMMARY
Rheumatic fever was a common disease in the Army during WorldWar II, particularly in certain geographic areas. It was observed in all degreesof severity, but the disease responded well to rest and the administration ofsalicylic acid and its derivatives. The course was usually monocyclic, andrecovery in all but a few cases was complete within a few months. Valvular heartdisease was a gratifyingly uncommon complication. The major problems encounteredwere those concerned with development of cardiac neurosis which was caused byoverly severe restriction of activity, apprehension on the part of the medicalofficers in charge, and inadequate programs for convalescent rehabilitation.This situation was greatly improved during the last 2 years of the war bythe creation of treatment centers.
Investigation of many aspects of the prevention andmanagement of rheumatic fever was carried out. Much pertained to the study ofthe close relationship between infection by group A hemolytic streptococci andthe 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.
