CHAPTER XVIII
Rheumatic Diseases
Richard T. Smith, M.D.
The importance of arthritis and other rheumatic diseases as acause of disability and noneffectiveness in military personnel was recognized bythe War Department in 1942, for although arthritis did not account for a largepercentage of illnesses in the Army, it had been found to be one of the mostdisabling. In anticipation of a formidable number of cases of rheumaticdiseases, and in an effort adequately to diagnose, treat, and salvage as manymilitary personnel as possible, not only for the World War II period but alsofor the long-range national economy, tentative steps were taken in the latterpart of 1942.
The Surgeon General and his staff, with the cooperation ofthe American Rheumatism Association, formulated a plan for the establishment ofone 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 andcenters for rheumatic fever, specifically for the care of the difficult orprogressive cases and the handling of diagnostic problems.
Toward the end of 1943, it became apparent that a center forthe treatment of chronic arthritis would be needed. Therefore, on 17 December1943,1 the Army and Navy General Hospital at Hot Springs, Ark., was designatedas a center for the diagnosis and treatment of rheumatic diseases. A secondcenter for chronic rheumatic diseases was authorized on 25 August 1944, atAshburn General Hospital, McKinney, Tex., to relieve the flow of patients at thefirst center.2 At the same time, the following three centers weredesignated for the care of soldiers with rheumatic fever: Birmingham General Hospital, Van Nuys, Calif.; Foster GeneralHospital, 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 ageneral hospital, established in 1882. On 20 June 1882, Congress passed an actappro-
1Letter,Headquarters, Army Service Forces, Washington, D.C., to Commanding Generals, allservice commands and Military District of Washington, 17 Dec. 1943,subject: General Hospitals Designated for Specialized Treatment.
2War Department Circular No. 347, 25Aug. 1944.
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priating $100,000 for the erection of an Army and NavyHospital on a Government reservation near Hot Springs, Ark. War DepartmentGeneral Orders No. 72, 5 July 1882, officially established the Army and NavyGeneral Hospital.3 The cornerstone was laid in 1883 on a site ofapproximately 15 acres. The hospital was opened for occupancy on 17 January1887.4 From that time until the last additional building was added on thehospital grounds in 1927, there was a daily average of 300 patients.
A new building for the Army and Navy General Hospital wasstarted in 1941 and completed in 1943, costing approximately $1,500,000. It wasa six-floor modern building with a total bed capacity of 518.
A short time after war was declared in 1941, the hospitalunderwent new expansion which more than doubled its bed capacity to a total of1,220. The Eastman Hotel situated across the street from the hospital waspurchased by the War Department on 13 October 1942. Considerable rehabilitationwas 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 usedexclusively for the housing and care of convalescent patients, which wouldminimize any fire risk although the building had been "fireproofed"throughout. In addition, other properties were purchased, including the EastmanHotel garage and the Hot Springs Hotel.
The reservation of 24.24 acres on the southwest slope ofNorth Mountain, approximately 650 feet above sea level, overlooked the mainintersection of Hot Springs. By utilizing the barracks and quarters which wereestablished, before the beginning of World War II, for a technicians' school,a rehabilitation center for ambulatory patients was also established. Inaddition, there were quarters for nurses, Wacs, and enlisted men; seven homesfor officers; and quartermaster and all other facilities for a self-containedarmy post.
When the Army and Navy General Hospital (fig. 61) wasdesignated a center for the diagnosis and treatment of rheumatic diseases amongAmerican soldiers, it and any others that might be established in the futurewere designed, as previously mentioned, for the care of difficult or progressivecases, or for the handling of diagnostic problems.
It was believed that the majority of soldiers who developedrheumatism would not be transferred to a center such as the Army and NavyGeneral Hospital. Patients with transient muscular rheumatism, mild rheumaticfever without carditis, or acute traumatic or specific infectious arthritiscould 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 wheredifficult
3Unless otherwise indicated, all dataon the Army and Navy General Hospital are from "Annual Reports, Army andNavy General Hospital, 1941-45."
4The Army and Navy General Hospital was closed on 30 November1959.
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cases can be studied by special methods and by medicalofficers with a special knowledge of rheumatic diseases.
2. Intensive treatment: to provide special facilities for thetreatment of the more severe or progressive cases.
3. Prompt disposition: to accomplish as great a reduction inhospitalization time as is consistent with adequate treatment.
4. Increase salvage: to restore to duty, if possible, all menwith "cured" or "arrested"disease.
5. Rehabilitation: to educate or rehabilitate for civilianlife those whose disability necessitates discharge from the Army.
6. Application of newer advances in treatment.
7. Appropriate clinical studies of patients while undertreatment.
8. Long-range economy, an incidental, but important aim: toreduce the costly need for disability pensions and prolonged hospitalization inveterans' facilities.
The Army and Navy General Hospital, the Army's oldestgeneral hospital, was chosen because of its past history and excellentfacilities. The
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adjacent Hot Springs which, since 1887, had been a mecca forrheumatic personnel of the Army, was a natural choice. An outstanding advantageof establishing a rheumatism center in a large general hospital provided variedmedical and surgical specialties which were necessary for proper knowledge andcomplete treatment of rheumatic diseases. This provided specialists in allfields of medicine to support the extreme specialization in the rheumaticdiseases.
The rapid growth of the rheumatism center is evidenced by thedaily census of the rheumatic disease section, which rose from 56 patients inJanuary 1944 to a total of 704 patients in October 1944. This is welldemonstrated in table 85 where the total admissions to the rheumatic diseasesection in 1943 was 556 patients, or 29 percent of the total admissions for thatyear. In 1944, it had increased to 3,105 rheumatic patients, 63.8 percent of thetotal 4,868 admissions in the year. Between 1 January and 30 June 1945, anadditional 2,210 rheumatic patients were admitted, or a total of 5,315 in 18months.
| | | | |
| |
| ||
| 1941 | 907 | 584 | 64.4 |
| 1942 | 985 | 516 | 52.4 |
| 19431 | 1,930 | 556 | 28.8 |
1944 | 4,868 | 3,105 | 63.8 |
1945 | 6,041 | 3,542 | 58.6 |
|
|
|
|
|
1Hospital designated a specialized center for treatment ofrheumatic diseases, 17 Dec. 1943.
Source: Annual Reports, Army Navy General Hospital, 1941-45.
Another evidence of the activity of the rheumatic diseasesection 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 1944and 1945, the professional personnel for the section increased to 9 and 18,respectively, with an allotment of 600 beds for these special patients. Otherfacilities, such as the physical therapy department, the occupational therapydepartment, a braceshop, and the physical rehabilitation area, also wereexpanded.
Organization of the rheumatic disease section.-During1944-45, the rheumatic disease section of the Army and Navy General Hospitalreached its maximum in space and function. With a total of 600 beds allocated tothis section (exclusive of beds for female patients), 90 percent of these
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were for ambulatory patients and were situated in the Eastmanannex. Ambulatory enlisted rheumatic patients were housed in seven completewards in the annex while nonambulatory patients were housed in one complete wardin the hospital building proper. Ambulatory rheumatic officers were housed intwo complete wards in the annex, while nonambulatory rheumatic officers werecared for in the officers' ward in the main building. Female rheumaticpatients were assigned to the female ward. There were actually eight completewards ranging from 60 to 83 beds, and parts of five other wards that wereutilized for patients assigned to this section.
Between 1 July 1944 and the end of 1945, the daily censusranged between 500 and 700 patients present in the section. In addition, therewere between 150 and 350 rheumatism patients on furlough at all times.
Year |
| Total officers in Medical Service | |
| Beds | ||
1942 | 2 | 111 | 15 |
1943 | 2 | 45 | 14 |
1944 | 9 | 600 | 22 |
1945 | 18 | 600 | 35 |
Source: Annual Reports, Army and Navy General Hospital, 1942-45.
The ratio of only 60 beds for nonambulatory patients and 540for ambulatory patients occurred partly owing to necessity and partly by design.The Eastman annex, containing 90 percent of all the beds in the rheumaticdisease section was not considered a suitable building for completely bedfastpatients. This constituted the necessity. It was the philosophy of the staff ofthe rheumatic disease section, and the design, that (1) less disability andpermanent crippling would occur if joints were not severely limited by excessiverest; (2) less rehabilitation and reconditioning would be required if patientswere forced to be active; and (3) morale would be higher if the severely ill bedpatients were physically separated from the ambulatory patients. An additionalbenefit also occurred in that the period of hospitalization was considerablyshortened.
Despite the fact that more than half of the patientstransferred to the Army and Navy General Hospital arrived as litter patients orhad been only semi-ambulatory at the time of admission, most of them wereinformed that they were now ambulatory and were assigned to wards in the annex.As might be expected, many of those newly designated ambu-
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latory patients were most unhappy with their new status. Thisrapidly changed when they realized that only in this category were they eligiblefor afternoon or evening passes, or for furloughs.
All special areas of the hospital were utilized for the besttreatment of the patients. Constant and frequent consultation with theorthopedic department was essential in providing the best treatment to thepatients. Where necessary, corrective or diagnostic operative procedures werecarried out. The physical therapy department participated in the treatment ofmost patients. All laboratory and diagnostic services were utilized for the bestbenefit of the patients.
The personnel of the section on rheumatic diseases in 1944consisted of nine medical officers. Three officers were qualified as specialistsin rheumatic diseases, one of whom was the chief of the section; one was apartially trained officer; and five officers were undergoing training (table86). The director of the rheumatismcenter was also the chief of the medical service.
In 1945, the staff of the section (fig. 62) was increased to18 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 thatan additional rheumatism center would be needed. The second rheumatism center,as already mentioned, was established at the Ashburn General Hospital.5 Thishospital became operative as a rheumatism center, on 1 September 1944. Therewere 729 beds allocated for arthritis. On 1 January 1945, by converting regularbarracks into wards, the bed capacity for rheumatic disease patients wasincreased to a total of 1,661. This hospital reached its peak of admissions toall sections of the hospital on 29 August 1945, when there was a total of 2,852patients. Thereafter, there was a steady decline of admissions and census in thehospital until 12 December 1945, at which time, with only 17 beds occupied, thehospital was declared surplus. During the first 8 months that Ashburn GeneralHospital functioned as a rheumatism center, admissions to the rheumatic diseasesection averaged more than 400 a month. During 1945, a total of 3,534 patientswere admitted to the section.
The rheumatic disease section consisted of 14 wards when itfirst began operation on 1 September 1944. The medical personnel consisted of achief of the section, assisted by four medical officers. This was an inadequatestaff for the size of the section, requiring the chief of the section to takepersonal charge of wards in addition to his other duties.
5Unless otherwise indicated, all dataon Ashburn GeneralHospital are from "Annual Reports, Ashburn General Hospital, 1944-45."
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The following objectives were the guide for organizing thesection:
1. To facilitate the prompt and proper care of patients uponadmission to the hospital.
2. To give all patients received from overseas a convalescentfurlough as soon as it could be determined such would not aggravate theirphysical condition.
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3. Definitive treatment, to emphasize teaching all patientsthe nature of their disease and the way to care for themselves in their homes.
4. To bring all patients with interesting or puzzlingfeatures of disease before conferences of the entire group of medical officers,and particularly to utilize the services of the orthopedic surgeon and theneuropsychiatrist in this connection.
5. To keep adequate records of each patient in order tocontribute as much as possible toward increasing knowledge of the type ofrheumatic diseases observed.
During 1945, the rheumatic disease section increased in sizeto four groups of six to eight wards. Each group of wards was under thedirection of one officer trained in the care of rheumatic diseases, whosupervised and taught the ward officers under his charge.
When patients were admitted to the hospital, they were placedin classification wards. The type and severity of their disease was estimated.Then, within 48 hours, they were transferred to another ward where definitivetreatment was started. Frequently, patients were permitted to proceed on theirinitial oversea furlough directly from these classification wards.
The officers' and women's section of the hospitalconsisted of seven wards with three to six medical officers. Most of thepatients had a rheumatic disease. One of the officers assigned to the section,trained in the care of rheumatic diseases, acted as consultant for the entiresection.
EPIDEMIOLOGY
The conditions imposed upon military personnel by militarycombat operations influenced the probabilities of an increased incidence of manyof the rheumatic diseases. The factors which would increase the hazards offibrositis, psychogenic rheumatism, and rheumatoid arthritis are emotionaldisturbances, repeated and prolonged exposure to extremes of temperature anddampness, poor personal hygiene, exposure to respiratory and other infections,musculoskeletal strain, fatigue, and joint trauma. An increased prevalence ofrespiratory infections would tend to increase the incidence of rheumatic fever.The rate of traumatic arthritis would increase, since injuries to joints wouldbe more common. Increased exposure to, and the occurrence of, gonorrhea wouldproduce more gonorrheal arthritis. Infectious arthritis with penetratinginjuries to joints would be more common.
Climatic conditions, often thought to be an important factorin the frequency and distribution of the rheumatic diseases, were of littleimport. The total incidence and that of the various rheumatic conditions wasessentially the same for those theaters and areas with wide differences inclimate, such as the continental United States, the Mediterranean theater,
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and the Southwest Pacific Area (table 87). The highest rateof admissions (21.21) was for the North American theater (including Alaska andIceland), while the lowest rate (10.72) was for the European theater, with acomparable climate. The next highest admission rates were found in the MiddleEast (18.61) and the Southwest Pacific theaters (15.24).
TABLE 87.-Admission rates forrheumatic diseases in the U. S. Army, by theater or area, 1942-45
STATISTICAL DATA
Anticipated Incidence
When the original planning for rheumatism centers wasundertaken, 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 "anticipatedincidence" based upon World War I and various peacetime studies. There weremany pitfalls in attempting to compare civilian rates with the Army rate;namely, the relative vagueness and unreliability of the diagnostic groupings andthe differences in age groups being considered since the Army consisted of youngmales. In addition, the Army diagnostic criteria differed considerably in thetwo 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 Atthis
6Hagerstown Morbidity Study, U.S. Public Health Service,Hagerstown, Md.
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rate, a total of 530,000 cases of rheumatic disease wouldhave 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 apossible 578,000 cases for the duration of the war. On the other hand, a rate of14 per 1,000 per year, arrived at by the Massachusetts survey in 1933,8suggested a total of 357,000 for the same period of hostilities.
During World War I, there were no special centers forrheumatic diseases, although there were 84,550 admissions with a primarydiagnosis of one of the rheumatic diseases.9 However, with the addition ofthose patients having a rheumatic disease as the secondary diagnosis, the totalincidence was approximately 107,000, or 26 per 1,000 average strength peryear.10 On this basis, the incidence of rheumatic diseases for World War IIwould have amounted to approximately 659,000.
It is quite evident that any effort to arrive at a realisticrate on the basis of the preceding figures would have been impossible. Anaverage of the four rates amounts to 21.25 per 1,000 per year. The rate whichmore nearly approximated the actual figure was the Hagerstown rate of 20.8. Thetrue incidence rate for World War II was 20.7 cases per year per 1,000 averagestrength, or 528,300 cases during the years 1942-45.11Thisconsisted of those patients primarily admitted to hospitals for a rheumaticcondition, as well as those cases secondary to or concurrent with otheradmission diagnoses.
Disqualification for Military Service Because of RheumaticDiseases
Any direct comparison between rejection rates of applicantsfor 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 thetwo wars, (2) differences in diagnostic criteria, and (3) differences in theprevailing medical standards. These data should not be used to draw definiteconclusions in regard to trends in the prevalence of the rheumatic diseases.
The examinees of World War I were younger than those in WorldWar II. Therefore, table 88 shows a comparison between those rejected formilitary service in World War I and the age group of 20-24 years in World WarII. It is clearly seen from this table that the medical standards were differentin the two wars; for instance, gonococcus infection of a joint, limitation ofmotion, and sacroiliac deformities were reasons for
7Preliminary Reports, The National Health Survey: 1935 to1936, Sickness and Medical Care Series. Bulletins Nos. 1 to 6, U.S. PublicHealth Service, Washington, D.C.
8Bigelow, George H., and Lombard, Herbert L.: Cancer andOther Chronic Diseases in Massachusetts. Boston: Houghton Mifflin Co., 1933.
9The Medical Department of the United States Army in the WorldWar. Washington: Government Printing Office, 1925, vol. XV, pt. 2.
10See footnote 9.
11Medical Department, United States Army. MedicalStatistics in World War II. [In preparation.]
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disqualification in World War II but not in World War I. Theincrease in the number of disqualifying defects should not be interpreted as anincrease in their incidence, but rather improvement in the diagnostic criteriaat the time of World War II.
[Rate expressed as number of disqualifications per 1,000examinees]
Diagnosis | Disqualified for World War I1 | Disqualified for World War II,2 ages 20-24 |
Ankylosis | 3.79 | 0.52 |
Arthritis | 1.71 | 1.41 |
Bursitis | .04 | .17 |
Gonococcus infection of joint | --- | .02 |
Limitation of motion | --- | 5.22 |
Muscular rheumatism | .32 | --- |
Myositis | .02 | .02 |
Sacroiliac deformities | --- | .56 |
Tenosynovitis | .02 | --- |
|
| 5.90 | 7.92 |
1Love, Albert G., and Davenport, Charles B.:Defects Found inDrafted Men. Washington: Government Printing Office, 1920, table V.
2Karpinos, B. D.: Defects Among Registrants Examined forMilitary Service, World War II (in manuscript form). Medical Statistics Division,Office of The Surgeon General, U.S. Army.
Hospital Admissions for Rheumatic Conditions
The disparity in the diagnostic terms for the rheumaticdiseases in World War I and World War II interferes with a direct comparison ofhospital 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 refersto the specified diseases reported as the primary cause for the patient'sadmission to a medical treatment facility. There were, in addition to thoseadmissions indicated in table 89, other diagnoses of specific rheumaticdiseases, secondary to or concurrent with some other admission diagnoses. Ifthese additional diagnoses were added to the primary rheumatic hospitaladmission rates, the total incidence rate for World War I would have been25.9 per 1,000 per year and for World War II, 20.7.
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TABLE 89.-Comparison ofadmission rates for rheumatic diseases (excluding rheumatic fever),World War I1andWorld War II2
[Rate expressed as number of cases per annum per 1,000 averagestrength]
World War I | World War II | ||
| Admissions | Diagnosis | Admissions |
Arthritis | 8.14 | Arthritis | 5.34 |
| (3) |
| Acute (type unspecified) | .88 |
| (3) |
| Chronic rheumatoid | .74 |
| (3) |
| Osteoarthritis | 1.21 |
| (3) |
| Other and unspecified | 2.51 |
Myositis | 1.00 | Myositis | 2.62 |
Synovitis | .87 | Synovitis | 1.19 |
Tenosynovitis | .65 | Tenosynovitis | .70 |
Ankylosis | .46 | Ankylosis | .12 |
Muscular rheumatism and certain other diseases of joints | 3.32 | Muscular rheumatism and certain other diseases of joints | 2.20 |
Gout | .02 | Tuberculosis of bone or joint | .02 |
| Gout and gouty arthritis | .05 | |
Bursitis | 1.41 | ||
|
| 20.46 |
| 13.65 |
1The Medical Department of the UnitedStates Army in the World War. Washington: U.S. Government Printing Office,1925, vol. XV, Statistics, pt. 2.
2Preliminary data based on sample tabulations of individualmedical records, 1942-45.
3In World War I, all arthritis,including osteoarthritis, was grouped under the single term"arthritis."
The admission rates for rheumatic diseases in the varioustheaters is shown in table 87. Some isolated butincomplete reports of the incidence of certain rheumatic diseases are availablefrom a few theaters; namely, a portion of the Latin American area, the NorthAfrican theater, and the western portion of the Central and South Pacifictheater.
In the Panama Canal Department, of the Latin American area,Gorgas General Hospital had a total of 23 patients with rheumatoid arthritisbetween 1 January 1940 and 1 October 1945; an additional eight cases werereported from other military hospitals of the Department for the period 1January 1941 to 31 December 1945.12 Mostof the patients had mild arthritis; 14 of the 23 from Gorgas General Hospitalwere returned to the United States for full evaluation and treatment.
In the Antilles Department,13 also of the LatinAmerican area, from 1942 to 1 October 1945, a total of 225 patients wereadmitted with rheumatoid arthritis to the 161st General Hospital, San Juan,Puerto Rico. The majority of these patients were separated from the militaryservice.
12Professional History of Internal Medicine in World WarII, 1 January 1940 to 1 October 1945, The Panama Canal Department, vol. I, p.73. [Official record.]
13Professional History of Internal Medicine in World WarII, The Antilles Department, pp. 39-40. [Official record.]
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The 359th Station Hospital, on Trinidad, however, had only 100admissions with a primary diagnosis of arthritis and 35admissions in which arthritis was a secondary diagnosis. Fifty-two of the firstgroup and 15 of the second group, or a total of 67, were transferred to generalhospitals. The remaining 68 patients were returned to duty. Only 15 of the 135patients were diagnosed as rheumatoid arthritis.
In the Mediterranean theater, in a group of 10 generalhospitals up to 1 December 1944, 3,260 patients were admitted with a diagnosisof arthritis, or 1.8 percent of the total 177,317 hospital admissions.14 Withrespect to a comparison between those patients admitted for a diagnosis ofarthritis versus the total number of admissions to the medical services of threegeneral hospitals (70th, 45th, and 12th), there were 1,157 patients with adiagnosis of arthritis, or 4.1 percent of the 28,251 medical patients.
Disposition of patients with arthritis in selected generalhospitals from the Mediterranean theater is presented in table 90. The datacollected from the 10 general hospitals were obtained by written questionnaires.The information from the 45th General Hospital, Rabat, FrenchMorocco, came from an examination of the records of themedical service. These are compared with the dispositions of the remainder ofmedical patients in the 45th GeneralHospital, as well as with the dispositions for all patients hospitalized formedical reasons in the entire theater. An inference can be drawn from this tablethat slightly less than half of those patients with arthritis reaching a generalhospital in that theater were evacuated, and approximately another one-fourthwere reclassified for limited service. When compared with the medical admissionsfor the entire
Source of patients | Total | Duty | Limited service | Evacuation | |||
| Percent | Number | Percent | Number | Percent | ||
Ten general hospitals | 2,938 | 956 | 32.6 | 692 | 23.4 | 1,290 | 44.0 |
45th General Hospital (Medical Service) | 329 | 63 | 19.1 | 130 | 39.6 | 136 | 41.3 |
Remainder of 45th General Hospital Medical Service | 5,222 | 3,341 | 64.1 | 534 | 10.2 | 1,347 | 25.7 |
Cases hospitalized for disease in theater, January 1943-April 1945 | 703,320 | 618,921 | 88.0 | 53,079 | 7.6 | 31,320 | 4.4 |
Source: Short, C.L.: Arthritis in the North African andMediterranean Theater of Operations, table 6. [Official record.]
14Short, C. L.: Arthritis in the North African and Mediterranean Theaterof Operations, table 3. [Official record.]
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theater, it is quite evident that the arthritic is much morevulnerable in these respects.
A geographic distribution of admissions for arthritis andarthralgia in five islands of the Western Pacific Base Command of the Centraland South Pacific theater is shown in table 91, as compared with the totalmedical admissions for the same islands. Most medical officers believed that thesymptoms causing hospital admission were directly related to the high humidityin this area of the Pacific regardless of whatever the underlying process mighthave been.15 This is of particular interest, for Iwo Jima, the driestof the islands in the Western Pacific Base Command, had the lowest incidence ofarthritic conditions. No specific data were presented in regard to thedisposition of these patients. In general, the criteria for evacuation were theseverity of symptoms and the persistence of sedimentation rate elevation,further influenced by such factors as the amount of time spent overseas and theamount of combat duty. Patients for evacuation were usually classed as "arthritis,"therefore, statistics of diagnosis may be considered as unreliable.
Island | Total medical admissions |
| |
| Percent of total admissions | ||
Angaur | 1,756 | 37 | 2.1 |
Guam | 3,909 | 119 | 3.0 |
Iwo Jima | 988 | 9 | .9 |
Saipan | 8,602 | 241 | 2.8 |
Tinian | 2,700 | 50 | 1.9 |
|
| 17,955 | 456 | 2.5 |
Source: Turner, Glenn O.: History of Internal Medicine of theWestern Pacific Base Command, table 4a. [Official record.]
Disposition of Rheumatic Diseases
During the period 1942-45, 64,619 enlisted and commissionedpersonnel were released from the Army because of rheumatic diseases (table 92).Of this number, there were 50 deaths. During this same period, 886,127 soldierswere separated from the service because of nonbattle disability. The 64,569rheumatic patients separated comprised only 7.3 percent of the total fornonbattle causes.
15Turner, Glenn O.: History of Internal Medicine of theWestern Pacific Base Command, 1945. [Official record.]
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The daily average noneffective rate during 1942-45, due tononbattle causes was 36.68 per 1,000 per average strength. The noneffective ratefor rheumatic diseases was 1.28, or 3.5 percent of the total. The diseases"acute arthritis," "chronic rheumatoid arthritis,""hypertrophic arthritis," and "other and unspecifiedarthritis" caused more noneffectiveness than all other rheumatic diseases.
TABLE 92.-Disabilityseparations, deaths, and noneffectiveness due to rheumatic diseases1in the U.S. Army, 1942-45
[Preliminary data based on sample tabulations of individualmedical records]
[Rate expressed as average daily number of noneffectives per1,000 average strength]
Diagnostic category |
| Number of deaths2 | Noneffective rate2 |
Arthritis, acute (type unspecified) | 262 | 0 | 0.05 |
Arthritis, chronic rheumatoid | 9,310 | 0 | .16 |
Osteoarthritis | 15,756 | 1 | .19 |
Arthritis, other and unspecified | 22,299 | 0 | .26 |
Synovitis | 2,373 | 0 | .09 |
Tenosynovitis | 146 | 0 | .03 |
Ankylosis | 4,355 | 0 | .02 |
Rheumatic fever | 5,544 | 29 | .19 |
Gout and gouty arthritis | 372 | 0 | .01 |
Tuberculosis of bone or joint | 422 | 17 | .01 |
Bursitis | 543 | 0 | .07 |
Myositis | 1,185 | 0 | .10 |
Muscular rheumatism and certain other diseases of muscles | 2,002 | 3 | .10 |
|
| 64,569 | 50 | 1.28 |
1Includes rheumatic diseases directly attributable totraumatisms.
2With respect to the disabilityseparation data, the specified condition was the cause of separation fromservice; regarding deaths, it was the underlying cause of death; and fornoneffectiveness, it was the cause of admission.
One of the outstanding purposes of the rheumatism centers ofthe U.S. Army was to conserve personnel, not only for military service but alsofor civilian life. Of 894 dispositions by certificates of disability fordischarge at the Army and Navy General Hospital in 1944, 501 (approximately 50percent) were due to rheumatic diseases that made the individuals unfit forfurther service. In 1945, 1,030 of 1,576, or about 56 percent, were also lostfrom service through certificate of disability for discharge. Everyconsideration was given to the possibility of conserving each of these soldiersfor further military service, on limited service if full duty was not possible.However, even limited duty can prove strenuous for military personnel withmusculoskeletal deformities or disabilities. None of those separated fromservice was considered suited to work as much as 8 hours a day.
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Most of the patients with fibrositis, "psychogenicrheumatism," rheumatic fever, or gonorrheal arthritis were returned toduty, while the majority of those with rheumatoid arthritis, osteoarthritis, orgout were separated from service. Generally, those patients with osteoarthritiswere older commissioned or noncommissioned officers who had had long service inthe Army. Soldiers suffering from gout or gouty arthritis were unsuitable formilitary life because of the impossibility of following a medical or dietaryregimen, and of the ever-present danger of provocative physical trauma. Theimpracticability of continuing in military service would be particularly true ifthere were frequent recurrences of acute gouty arthritis even in persons onlimited military service.
The disposition of rheumatic patients by diagnosis at theArmy and Navy General Hospital is shown in table 93. These are not consecutiveadmissions but rather groups of patients including enlisted men and officerswith various diagnoses. No final statistics are available regarding thedisposition 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 ofpatients with rheumatoid arthritis has been separation from the Service uponcertificate of disability and it is probable that this will continue to be thecase."
Condition | Number of patients | Returned to duty | Separated from service, medical discharge or retirement | ||
| Percent | Number | Percent | ||
Rheumatoid arthritis, including rheumatoid spondylitis | 500 | 76 | 15.2 | 424 | 84.8 |
"Psychogenic rheumatism" | 200 | 128 | 64.0 | 72 | 36.0 |
Fibrositis, primary | 150 | 123 | 82.0 | 27 | 18.0 |
Osteoarthritis | 100 | 38 | 38.0 | 62 | 62.0 |
Rheumatic fever | 50 | 39 | 78.0 | 11 | 22.0 |
Gonorrheal arthritis | 20 | 13 | 65.0 | 7 | 35.0 |
Gout | 10 | 1 | 10.0 | 9 | 90.0 |
Miscellaneous and unclassified cases of arthritis and "rheumatism" | 270 | 171 | 63.4 | 99 | 36.6 |
|
| 1,300 | 589 | 45.3 | 711 | 54.7 |
Source: Hench, P. S., and Boland, E. W.: The Management of Chronic Arthritisand Other Rheumatic Diseases Among Soldiers of the United States Army. Ann. Int.Med.24: 822, May 1946.
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CLINICAL PICTURE
In the early period of World War II, most of the rheumaticdisease patients admitted to the Army and Navy General Hospital had beenreceived from various military establishments throughout the continental UnitedStates, but by early 1944, the majority of patients were arriving from overseahospitals. Many were returned by ship from the South Pacific Area or from theEuropean theater. Others were transported by ambulance planes of the MilitaryTransport Command. Some patients had arrived by plane within 4 to 6 days afterleaving hospitals in the South Pacific (for example, within 4 days from Saipanto Hot Springs); others within 3 to 7 days from England, Italy, or France (forexample, from Paris to Hot Springs in 3 days). This rapid evacuation ofrheumatic soldiers from oversea hospitals to a hospital equipped especially fortheir needs was a strong morale builder among the military personnel and theirvery anxious relatives. In addition, the promptness of diagnosis and dispositionand the adequate treatment programs also raised and maintained morale.
Unfortunately, no official final figures on the relativeincidence of the rheumatic diseases are available from the Army and Navy GeneralHospital. From 1942 to 1945, there were 7,719 rheumatic disease admissions, ofwhich 86.1 percent (6,647) occurred during 1944-45 (table 85). Very definiteinformation can be gleaned from a survey of the first 2,000 consecutiveadmissions to the rheumatic disease section and the first 5,000 admissions(table 94). Since the patients sent to the rheumatism centers are selected, acensus from such installations does not reflect a relative incidence of therheumatic diseases in the Army as a whole. All the common forms of rheumaticdiseases, as well as most of the rarer types, were seen at this rheumatismcenter.
As might be anticipated, rheumatoid arthritis presented thelargest group of patients, affecting approximately one-third of all thoseadmitted to the section. Approximately one-fifth of the patients admitted as"rheumatic" had no evidence of organic skeletal disease. Thesepatients were suffering from a psychoneurosis which was manifested bymusculoskeletal symptoms, a condition which had been termed by some as"psychogenic rheumatism,"16 and byothers as "psychoneuroticrheumatism,"17 or"psychosomatic rheumatism."18 Therelative use of soldiers was largely responsible for the low incidence of goutand gouty arthritis. The highest incidence for gout was 1 percent as comparedwith approximately 4 to 5 percent frequently seen in civilian rheumatismclinics. The incidence
16Boland, E. W., and Corr, W. P.: Psychogenic Rheumatism.J.A.M.A. 123: 805-809, 27 Nov. 1943.
17Halliday, J. L.: Psychological Factors in Rheumatism; aPreliminary Study. Brit. M.J. 1: 213-217, 30 Jan. 1937; 264, 6 Feb. 1937.
18Halliday, J. L.: Concept of Psychosomatic Rheumatism.Ann. Int. Med. 15: 666-677,October 1941.
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Diagnosis |
| 5,000cases,2 percent | |
| Percent | ||
Rheumatoid arthritis | 686 | 34.3 | 35.2 |
| Peripheral | 390 |
|
|
| Spondylitis | 209 |
|
|
| Both | 87 |
|
|
Psychogenic rheumatism | 375 | 18.8 | 14.8 |
| Pure (without organic disease) | 231 |
|
|
| Superimposed (with organic disease) | 101 |
|
|
| Residual (following organic disease) | 43 |
|
|
Fibrositis primary | 272 | 13.6 | 14.6 |
Osteoarthritis | 249 | 12.4 | 11.4 |
| Primary | 210 |
|
|
| Secondary | 39 |
|
|
Rheumatic fever | 41 | 2.0 | 1.6 |
Gonorrheal arthritis | 27 | 1.4 | .8 |
Gouty arthritis | 18 | .9 | 1.0 |
Specific infectious arthritis | 9 | .5 | .3 |
Rarer types of arthropathies | 43 | 2.1 | 3.0 |
Joint tumors | 8 | .4 | .3 |
Miscellaneous conditions | 176 | 8.8 | 9.9 |
Nonclassified rheumatism and arthritis | 96 | 4.8 | 8.2 |
1Annual Report, Army and Navy General Hospital, 1944.
2Annual Report, Army and Navy General Hospital, 1945.
of gonorrheal arthritis was quite low because of thechemotherapy which was available.
Approximately one-third of the patients with rheumatoidarthritis had rheumatoid spondylitis. This relative incidence was surprisinglyhigh and in considerable contrast with experiences in civilian practice. Formany months at a time, there were between 70 and 100 cases of rheumatoidspondylitis in the hospital. This rather high incidence was probably due tothree factors: (1) Rheumatoid spondylitis affects males much more often thanfemales and especially young males of military age (18-30 years); (2) the early symptoms of the disease, including vagueintermittent low back pain, are difficult to evaluate and an early diagnosis hadfrequently not been made, including failure to recognize it in young men as theywere being inducted into the Army; and (3) the strenuous physical exertion ofarmy life and the training to which they were exposed probably soon aggravatedthe symptoms and revealed the early previously undiagnosed patients. Theincidence of the various rheumatic diseases at the Army and Navy GeneralHospital and at Ashburn General Hospital are within about the same limits (table95).
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TABLE 95.-Comparisonof incidence of various rheumatic diseases among first 2,000 cases at Army and Navy General Hospital1 and first 800 cases at Ashburn General Hospital2
Diagnosis | Army and Navy General Hospital (Percent) | Ashburn General Hospital (Percent) |
Rheumatoid arthritis | 34.3 | 38.3 |
Psychogenic rheumatism | 18.8 | 16.1 |
Fibrositis | 13.6 | 4.8 |
Osteoarthritis | 12.4 | 26.7 |
Rheumatic fever | 2.0 |
|
Gonorrheal arthritis | 1.4 | 1.4 |
Gouty arthritis | .9 | .6 |
Specific infections | .5 | .2 |
Joint tumors | .4 | .7 |
Miscellaneous conditions | 15.7 | 11.2 |
1Annual Report, Army and Navy General Hospital, 1944.
2Personal communication from Col. J. B. Anderson, Lt. Col. John Harvey, Maj.David M. Kydd, and Lt. Charles W. Fogarty, Jr., Ashburn General Hospital.
PROBLEMS OF DIAGNOSIS
The first stated aim of the rheumatism centers was to provide "accuratediagnosis" (p. 478). The absolute necessity of this aim was indicated bythe first admissions to the centers and emphasized and reemphasized with eachsucceeding group of admissions. The commonly stated transfer diagnoses of"acute arthritis," "chronic arthritis," or simply"arthritis" were inadequate for instituting proper therapy, estimatingprognosis, or planning for the disposition of the patients. In fact, these termsoften constituted no diagnosis at all. There were scores of patients with adiagnosis of "arthritis" who had no arthritis at all. There werepatients who were presumed to have "osteoarthritis" when they reallyhad rheumatoid arthritis or vice versa. Very few patients with gout werecorrectly diagnosed. A large proportion of soldiers transferred because of"muscular rheumatism," "myositis," or "fibrositis"were suffering from "psychogenic rheumatism." These errors were notreflections on individual medical officers but rather revealed the inadequatediagnostic level of the medical profession in rheumatologic matters, pointing upthe extreme need for a wider and more critical understanding of the fundamentalsof diagnosis in disease of the joints.
There were also several special problems relating to differential diagnosis.These included post-gonorrheal rheumatoid arthritis versus gonorrheal arthritisand psychogenic rheumatism versus fibrositis.
Post-Gonorrheal Rheumatoid Arthritis Versus Gonorrheal Arthritis
That rheumatoid arthritis could be precipitated by gonorrheal infection, justas by tonsillitis, influenza, or some other acute infection, was not
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well understood. In addition, the possibility that a verymild or non-symptomatic rheumatoid arthritis could be aggravated by an acutegenital gonorrhea was usually overlooked. Neither of those instances should havebeen considered as intimately involved with a venereal disease, but simply asrheumatoid arthritis precipitated by an acute infection which just happened tobe a venereal disease. It was reported in the First World War by Pemberton andhis associates19 thatapproximately 1 percent of the cases of chronic arthritis seen among soldiersbegan in close relationship with the onset of gonorrhea.
Proved gonorrheal arthritis among American soldiers wasapparently rare. Many more patients with a rheumatoid arthritis, precipitated oraggravated by a gonorrheal infection, were seen at the arthritis centers.Unfortunately, the majority of these patients were improperly labeled gonorrhealarthritis. They were unsuccessfully treated for this condition, before transfer,with sulfonamides, penicillin, or fever therapy, then sent to the center with adiagnosis of "gonorrheal arthritis resistant to penicillin and/orsulfonamides." Almost invariably those so-called cases of "gonorrhealarthritis resistant to chemotherapy" turned out to be rheumatoid arthritis,as shown by their subsequent course, their response to therapy, and in somecases, by articular biopsy.20
Many of these soldiers were on a limited pay status, inkeeping with the regulations regarding treatment of a venereal disease. Promptcorrection of the diagnosis improved the morale of the patient by reinstatinghis normal pay; it also permitted a realistic prognosis and the institution ofproper therapy.
Psychogenic Rheumatism
Most physicians were familiar with psychoneurosis as it couldmanifest itself by symptoms referable to the gastrointestinal tract, thecardiovascular system, et cetera. Apparently, a large proportion of the medicalprofession was not familiar with psychoneurosis as it affected the locomotorsystem.
"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.
20Hench, P. S., quoted by Harrell, W. E.: Penicillin and Other Antibiotic Agents. Philadelphia and London: W. B. Saunders Co., 1945, p. 348.
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matism," or "psychosomatic rheumatism."However, it was found expedient to use the term "psychogenicrheumatism," because of its compactness and its understandability. Manyindividuals who were inadequate or unable to adapt to military lifeunconsciously found some solution to their problems by musculoskeletalcomplaints which were often misinterpreted as "rheumatism" or"arthritis." Those patients did have symptoms, although they were notobjective or constitutional, nor could roentgenographic or biochemicalmanifestations of disease be found. It was most unusual for them to have anyreal rheumatism, synovitis, arthritis, or organic muscular lesions. On the otherhand, if some minor musculoskeletal condition did exist, it was insufficient toaccount for the severity of the disability. Many times, those patients wouldhave functional complaints referable to other systems as well. The severity ofthe psychoneurosis could vary from that of a very mild tension state to a majorconversion hysteria; not unusual were bizarre gaits, peculiar articular posturesand camptocormia (a forward bending of the trunk of the body, often a symptom ofsome traumatic neurosis), or flexed fingers caused by hysteria.
It is notable that from 16 to 19 percent of the rheumatismpatients admitted to the several rheumatism centers had no significant organicrheumatic disease (table 95). A prompt recognition of the presence of"psychogenic rheumatism" soon after the complaint was first made couldhave gone a long way in reversing this condition before it had become wellestablished by a long period of complaining. This might very well have providedbetter conservation of manpower, as well as reduction of pension payments afterseparation 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 thecondition for better or for worse. In contradistinction, the person with"psychogenic rheumatism" is a victim of his internal environment: thesymptoms vary depending upon mood or psyche, pleasure, excitement, mentaldistraction, worry, or fatigue. The differentiation proved very difficult if apatient had a mild fibrositis with a marked functional overlay.
TREATMENT OF THE RHEUMATIC DISEASES
When the first rheumatism center was established, The SurgeonGeneral, Maj. Gen. Norman T. Kirk, said, "Don't make the center arheumatism repository." This was outstanding advice, since nothing could
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destroy a soldier'spotentialities for salvage (his morale, his will to recover and to return toduty) more readily than the atmosphere of a "chronic hospital," or a"rheumatic old soldiers' home." The majority of the personneladmitted to the center had already been hospitalized for prolonged periods oftime, 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, orwhether they would be discharged from the Army. The most immediate question intheir minds was what the future might hold for them.
Certainly, for the best interests of the military, as well asthe 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, aprompt examination of the patient with a definite diagnosis was necessary at theearliest possible moment. The soldier was informed whether a prolonged period oftreatment was going to be necessary, whether he would remain in the hospitalonly a short time, and what the possibilities were for him to return either tomilitary duty or to civilian employment. An overlong hospitalization couldeasily turn an individual into a soldier with a hospital habit and decrease hissalvageability. Even though previously well oriented, he might become ahospital-engendered psychoneurotic with a fixation on illness and a functionaloverlay that could be more difficult to treat than the original organiccondition upon which it wassuperimposed.
It was a policy, therefore, that immediately upon arrival atthe hospital the patient was informed that he could be certain his period ofhospitalization would not be indefinite; that after a few days of thoroughinitial physical examination and study a progressive, well-oriented program ofintensive treatment would be initiated; and that, if hehad been serving overseas for a prolonged period of time, a furlough would bearranged as soon as possible. Under any circumstances, he would be informed thathis intensive treatment, either before or after furlough, would probablycontinue for 3 to 8 weeks or longer, if necessary, but he would be toldthe possibilities for reconditioning him to a useful way of life. Every effortwas made to maintain a pleasant atmosphere in the hospital and annex which wouldbe conducive to high morale and optimism rather than pessimism.
The comprehensive schemes of treatment used at the rheumatismcenter for the various rheumatic diseases were those approved bythe American Rheumatism Association,21 and used by the leadingrheumatologists of the country. Although the rheumatism center did have unusualfacilities for physical therapy and hydrotherapy, these facilities were usedproperly 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.
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exclusion of any other useful measure. For the most part,rheumatic patients were gentle, docile, and well behaved. They really asked verylittle of their physicians; they apparently were aware that no elusive"rapid cures" were available but they did look for a diagnosis and aman-to-man understanding of what they were up against, what they could do forthemselves, and what they should do to prevent making themselves worse. Thistype of patient had very little respect for a physician who tended to brush themoff with an incomplete diagnosis or who gave them a fancy diagnosis in medicalterms 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 weregiven in layman's language. There were 12 different lectures. Two or three ofthem were oriented on general topics for all patients; others were given only tothe appropriate group, depending upon the particular disease with which theysuffered. Patients with one diagnosis were not admitted to the specific lecturedesigned for those with a different diagnosis. Very particularly, patients with"psychogenic rheumatism" were not permitted to attend the lectures forpatients with rheumatoid arthritis or fibrositis, simply to prevent them fromdeveloping misinterpretations of their own conditions. There were special talksdesigned for this particular group of patients and their needs which were givenjointly 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.
2. Facts, fads, and false concepts about rheumatism.
3. Fibrositis-its meaning and management.
4. Rheumatoid arthritis and its management.
5. Rheumatoid spondylitis and its management.
6. Facts about osteoarthritis.
7. Gout and gouty arthritis.
8. Shoulder disabilities and their management.
9. Body mechanics in relation to disability of joints.
10. Home physical therapy (motion picture and demonstration).
11. Emotional tension and its relation to"rheumatism."
12. The management of rheumatic fever.
These group lectures were not a substitute for but rathersupplemental to individual consultations with ward officers. The lectures weredesigned to project the individual beyond his period of Army hospitalization andactually into his home and to indicate at least some of the benefits that hemight derive from the more formal treatment received in the hospital. They alsoserved as an introduction to the advice which each patient would receive fromhis home physician. These lectures were
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well received and proved to be a great timesaver for the busymedical officers. The recipients of the lectures were encouraged to askquestionsat the end of each lecture, particularly on points that bothered them or thatthey did not understand. They were informed at the time for questions that anyquestion, no matter how trivial it might seem, was a valid question. It wasfound that these lectures tended to improve morale. Probably, this was becauseeach individual discovered that he was not alone with
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his own problem but that others were as bad as or worse thanhe was and that he had every reason to take courage.
Rheumatoid Arthritis
The treatment for peripheral rheumatoid arthritis was quitestandard and included, among other things, the removal of obviously infectedfoci, the providing of highly nutritious diets (but no food fads,"anti-rheumatism vitamins," or specific diets), foreign protein fevertherapy in selected cases, simple analgesics, physical therapy, occupationaltherapy, orthopedic measures to prevent or correct deformities, and gold salts carefullyadministered to selected patients whose rheumatoid arthritis was progressivedespite the use of other more conservative measures. These various measures wereblended along with physical reconditioning to restore the best function thatcould be achieved for each patient.
Rheumatoid Spondylitis
The characteristic posture of patients with rheumatoidspondylitis dictated the stress that was placed on posture training. It was ahighly successful part of the total treatment program, producing correction or nearcorrection of the posture in all but those patients whose spines were ankylosedin an abnormal posture. Probably much of the success of posture training was dueto generally successful relief of pain by roentgen therapy.
X-ray therapy appeared to relieve pain and probably halt theprogression of the disease. For the purpose of treatment the spine was dividedinto four areas; namely, (1) the sacroiliac joints and lumbar spine; (2) thelower 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 threeor four divided doses was administered to each segment of the spine involvedclinically. Treatments were given every other day, with all areas treated within9 or 10 days. A second course of therapy would be givenafter an interval of 3 months if symptoms persisted.
All the adjunctive therapy, with the exception of goldtherapy, mentioned in the treatment of peripheral rheumatoid arthritis, was alsoemployed in these patients.
Osteoarthritis
Despite the X-ray evidence of osteoarthritis, most of thepatients had a moderate to severe secondary fibrositis with muscle atrophy. Thetreatment program was directed against both conditions.
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These patients were given salicylates and heat treatments forthe relief of pain. Weight-bearing joints were stabilized by improving musclestrength and orthopedic supports when required. The patients were instructed inways and means of modifying their living habits to decrease the further wear andtear in the involved joints.
The treatment of osteoarthritis of the cervical spine, inaddition to the general treatment already outlined, received intermittent Sayrehalter cervical traction and posture training. The traction was very effectivein relieving the radicular pain of this type of osteoarthritis.
Fibrositis
One of the most important elements in the treatment of eitherprimary or secondary fibrositis was the assurance that this was not a type ofarthritis and that it was a self-limited condition with no residual deformity.Salicylates and heat were given for relief of pain. Muscle rehabilitation andposture training exercises were prescribed and carefully supervised.
Psychogenic Rheumatism
The treatment of psychogenic rheumatism, although veryinteresting, posed a most difficult problem, second only in importance to thetreatment of rheumatoid arthritis. Although it was a pleasure to be able toreassure soldiers with psychogenic rheumatism that they had no arthritis ormuscular rheumatism and that they need not fear that they had a cripplingdisease, it was always tempered by the difficulty of helping them to developinsight and accept the diagnosis, at least to the point of submittingwholeheartedly to a trial of psychotherapeutic reconditioning. Of course, thelatter was much more important than physical reconditioning for this group ofpatients. Any attempt to use physical reconditioning alone in this type ofpatient accomplished little or nothing.
Those particular patients were not generally given formalcourses of physical therapy or other treatments that would be used for"organic rheumatism," except as diagnostic or therapeutic tests. Thiswas because many treatments of this type tended to fix more firmly in theirconsciousness the belief that they had a true organic disease.
Gouty Arthritis
The acute attacks of gouty arthritis were treated withcolchicine. These patients were carefully instructed in the constitution and useof low-purine diets as a means of decreasing the serum uric acid level and todecrease the number of acute attacks. Large doses of aspirin for three
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to four successive days each week were administered for theuricosuric effect. Concomitant with the aspirin administration, sufficientsodium bicarbonate was given to maintain the urine in an alkaline state toprevent, as far as possible, the formation of uric acid stones.
Miscellaneous Therapy
Acute gonorrheal arthritis and other specific infectiousarthritis were treated with penicillin, followed by rehabilitation. Bursitis andtenosynovitis were treated with heat, rest of the part and splinting ifnecessary, followed by rehabilitation and restoration of function when possible.Joint tumors, villus synovitis, and joint biopsies were transferred to theorthopedic department for the surgery required.
RECONDITIONING
The task of getting a convalescing soldier physically andmentally prepared to return to military duty is generally spoken of asreconditioning.22
A soldier with rheumatic disease who was considered to besalvageable was "reconditioned" in severalsteps. 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 livedin a convalescent barracks and participated in a daily program of physicalactivity carefully measured to his abilities. Before his transfer to thereconditioning barracks, he was frequently assigned, along with three to fiveother soldiers with essentially the same needs for reconditioning, to anoncommissioned officer patient who had already transferred to the convalescencebarracks or was about to do so, who would periodically gather his squad togetherand supervise the performance of the reconditioning exercises assigned on theward.
The ability of these patients to participate inreconditioning and convalescent programs was determined by the ward officer.Some, of course, with transient rheumatic disease could participate in verystrenuous programs. Other patients who could only be expected to return tolimited service at the most were recommended for less strenuous activities. Inevery instance, however, an attempt was made to apply the reconditioning programon an individual prescription basis.
REHABILITATION
If the type of rheumatic condition from which the soldiersuffered precluded the possibility of his return to duty within a reasonableperiod
22Hillman, C. C.: The Reconditioning Program in Army ServiceForces Hospitals. Mil. Rev. 24: 10-12, April 1944.
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of time, particularly if his disease was essentiallyprogressive and disabling, he would be considered ready for a discharge tocivilian life and for subsequent followup treatment by his civilian physicianor, if necessary, by a veteran's facility. The Army acknowledged an obligationto a soldier in this category, just as for one who might return to some form ofduty. It was necessary to prepare soldiers, not only physically but mentally, toreturn to a useful civilian life despite the rheumatic disability. This wasspoken of as rehabilitation.
Since, after discharge from the Army, the arthritic patientmay find it necessary to modify the pattern of his life to a considerable extentto avoid certain factors that might aggravate his disease, it was necessary toinstruct him to make only those alterations in his life that were unavoidablebut not to the extent of engendering defeatism. The educational program,including the group lectures, and the individual consultations with the wardofficers were the chief weapons against the dangers of a wheelchair or crutchpsychology. Every attempt was made to have each discharged arthritic patientcontinue to regard himself as a vital unit of his community. Every effort wasmade to teach him to live with his disease, not for it. This was the onlypossible way to make him consider his rheumatism as an avocation rather than avocation. If he should prematurely or needlessly consider the disease avocation, then he had taken too long a step toward the sterile existence of thepensioner's rocking chair.
It was the policy of the rheumatism centers to considerpatients with rheumatoid arthritis, particularly when it was progressive, aseligible for discharge. However, even many of those patients were salvageable,particularly if they had a good insight into their disease and were only mildlyaffected.
On the other hand, the disposition of patients withpsychogenic rheumatism required even more individual consideration. Manysoldiers affected with psychoneurosis of a mild or moderate degree could beexpected to render effective service. When, despite conscientious treatment,psychogenic rheumatism persisted to the extent that its victim no longerrepresented a unit of manpower, there was no other recourse but to recommend himfor discharge.
The standing order was "to conserve manpower." Themission of the rheumatism center was to diagnose and treat chronic rheumaticillnesses in an effort to salvage as many men as possible. Despite the mostdedicated attempts, only about 45 percent could be returned to some type ofduty.
TRAINING
From the time that the rheumatism centers became functional,there was a need for training medical officers in the diagnosis and treatment
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of rheumatic diseases. All ward officers had frequentconferences with the chief of the rheumatic disease section to present theirfindings on all new admissions, to discuss progress of patients receivingtherapy, and to plan for dispositions of patients. In addition, there wereweekly staff conferences and X-ray conferences to discuss the rheumaticdiseases.
The director of the rheumatism center conducted a weeklyclinic as a part of the educational program for officers assigned to thesection, and for visiting officers, local physicians, and other interestedmembers of the staff.
It was very fortunate that the medical consultant for theEighth Service Command was an eminent rheumatologist. At the time of hisperiodic visits, several days were devoted to the presentation and discussion ofcases, methods of therapy, ward rounds, and stimulating roundtable discussions.
CLINICAL INVESTIGATION
"It is hoped to make this hospital a source of extensiveknowledge on arthritis for the whole medical profession.Studies will be carried on in the use of special drugs, such as sulfonamides andpenicillin, in the treatment of arthritis." This is an excerpt from the WarDepartment announcement of the establishment of the first rheumatism center atthe Army and Navy General Hospital. It was evident that the Army realized therewas an obligation, not only to the soldier with arthritis as an individual, butalso as a representative of all human beings with the same problems. Thephysicians in the various rheumatism centers were encouraged to improve theirclinical knowledge and, if possible, the methods of treatment for the benefit ofthe entire medical profession. A constant effort was made to fulfill theseobligations by clinical investigations carried out in all centers. Despite thenewness of these centers, they rapidly became the largest rheumatism facilitiesin the world. They were both treatment centers and supervised schools ofrheumatology for physicians assigned temporarily for instruction. They provideda unique opportunity to benefit the rheumatic soldier, his medical officer, themedical profession, and humanity as a whole.
The clinical investigations at the Army and Navy GeneralHospital during the year 1944 were as follows:
1. Penicillin was found to be ineffective against rheumatoidarthritis.
2. Penicillin was found to be an important adjuvant in thetreatment of agranulocytosis resulting from chrysotherapy; that is, as atreatment for the infections which may complicate an agranulocytosis.
3. Studies on the incidence of various types of rheumaticdiseases admitted to the facility, as well as pertinent observations on themilitary aspects of the common rheumatic diseases.
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4. Studies on psychogenic rheumatism and its differentiation from fibrositis.23In the course of this study, differentiation between fibrositis and"psychogenic rheumatism" was developed (table 96).
TABLE 96.-Differentiation between fibrositis and "pyschogenic rheumatism"
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.
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The factors underlying psychogenic rheumatism were determinedto be different kinds of fears and frustrations. More specifically theyconsisted of (1) combat fatigue-less stable soldiers reached the saturationpoint when the subconscious demand for self-preservation caused the developmentof musculoskeletal symptoms to save the man's life or his mind; (2)maladjustment to discipline, criticism, or a menial job; (3) lack of privacycaused by military herding; (4) homesickness and loneliness; (5) worry aboutfamily finances or illness; (6) worry about lack of promotion; and (7) worryover fidelity of wife, fiancee, or even himself.
Successful treatment was dependent upon the awareness thatthe soldier had psychogenic rheumatism and that psychiatric treatment was necessary.This type of individual could frequently be salvaged since the resultof psychiatric treatment was often most gratifying.
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5. Differential diagnosis between post-gonorrheal rheumatoidarthritis and gonorrheal arthritis.
The joint lesion of gonorrheal arthritis was known to be asevere, rapidly destructive infectious arthritis. Without specific therapy toovercome 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 GeneralHospital were seen 3 to 6 months after the onset of the arthritis. Adequatepenicillin and sulfonamides, or both, had been administered previously with nobenefit to the joint involvement. Instead of the hot, inflamed, excruciatinglypainful joint of an acute infection, these patients had a chronic, mild tomoderately painful joint or joints. Differentiation of a rheumatoid arthritisprecipitated by the acute infection of a venereal gonorrheal arthritis was madeby (1) the subsequent course of a chronic rheumatoid-like arthritis often withadditional joints becoming involved; (2) therapeutic tests with penicillin whenindicated; and (3) biopsies of the joints when indicated.24
6. Further studies on palindromic rheumatism. The clinicalcharacteristics of palindromic rheumatism as first reported25 were confirmed. Varioustherapies were tried, including purine-free and low-purine diets, coichicine,intravenous and oral calcium preparations, and search for anderadication of foci of infection and febrile reactions with intravenous typhoidvaccine. The last seemed to have a measure of success, but often only of atemporary nature for a few months.
During the year 1945, the investigative program at the Armyand Navy General Hospital was more extensive, largely because the rheumatismcenter was more firmly established; more trained rheumatologists were assignedto the rheumatic disease section; and more medical officer trainees, who wereinterested in assisting in the various studies, were assigned to the hospital.The clinical investigations for that year were:
1. Cardiac changes occurring inrheumatoid arthritis-a clinical and electrocardiographic study.
2. Further studies on palindromic rheumatism. Thisinvestigation was a continuation of the one begun in 1944. Atypicalforms of palindromic rheumatism and various types of onsets and clinical coursesof the disease were becoming apparent. Some of thesepatients appeared to have bouts of rheumatoid arthritiswhich cleared within a few weeks, leaving no residuals.This latter type of arthritis was differentiated into "episodicrheumatoid arthritis."26
24See footnotes 20, p. 496, and 23, p. 506.
25Hench, P. S., and Rosenberg, E. F.: PalindromicRheumatism. Arch. Int. Med. 73: 293-321, April 1944.
26Hench, P. S.: Episodic Rheumatoid Arthritis. Arizona Med.4: 62, 1947.
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The studies of palindromic rheumatism and the failures of thevarious forms of treatment, as well as the gradual development of a chronicrheumatoid arthritis in some cases, raised the question as to whether it mightnot be an atypical form of rheumatoid arthritis. These impressions led to atrial of gold therapy in these patients.27Three patients weretreated with a favorable response to gold thioglucose.
3. The diamidines in the treatment ofrheumatoid arthritis.
4. The clinical and pathologic features of psoriaticarthritis and psoriatic arthropathy.
5. Rheumatoid spondylitis-a study of 100cases with special reference to diagnostic criteria.28This was astudy 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 thedisease. Patients with unequivocal evidence of the disease were included. Eachpatient was questioned in detail in order to determine the symptoms whichoccurred prior to the finding of definite spinal involvement. It was determinedthat the onset was insidious. By a correlation of the symptoms as the diseaseprogressed, with X-rays, it was determined that the earliest roentgenographicchanges appeared in the sacroiliac. It was recommended that rheumatoidspondylitis should be suspected in young men with recurrent or persistent lowback aching and stiffness, and that the sacroiliac joints should be examined forthe characteristic changes which they had found of a bilateral sacro-illiitis.
6. Rheumatoid spondylitis-correlation of clinical androentgenographic features.29 A group of 50 soldiers with definiteX-ray evidence of rheumatoid spondylitis were studied. Intwo-thirds of these patients, the clinical findings wereadvanced to a greater degree than the roentgenographic changes. Attempts weremade to find explanations for all the symptoms in relationto the extent of involvement. Since clinical involvement was at least one or twospinal segments higher than the roentgenographic evidence,if X-ray therapy was to be administered it should be chosenon the basis of the clinical involvement.
7. The cerebrospinal fluid in rheumatoid spondylitis.30Since rheumatoid spondylitis must be differentiated from other causes of chroniclow back disability, this study was undertaken to determine whether biochemicalstudies of cerebrospinal fluid might afford data upon which clearand early differentiations could be made.
27Boland, E. W., and Headley, N. E.: Treatment of So-CalledPalindromic Rheumatism With Gold Compounds. Ann. Rheumat. Dis. 8: 64-69, March1949.
28Boland, E. W., and Present, A. J.: Rheumatoid Spondylitis;Study of 100 Cases With Special Reference to Diagnostic Criteria. J.A.M.A. 129:843-849, 24 Nov. 1945.
29Boland, W. E., and Shebesta, E. M.: RheumatoidSpondylitis; Correlation of Clinical and Roentgenographic Features. Radiology47: 551-561, December 1946.
30Boland, E. W., Headley, N. E., and Hench, P. S.:Cerebrospinal Fluid in Rheumatoid Spondylitis. Ann. Rheumat. Dis. 7: 195-199,December 1948.
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Moderate increases in protein content of the spinal fluidwere found in patients with rheumatoid spondylitis. Theincrease was due largely to the severity of the disease rather than theduration. The elevation of spinal fluid protein was found to be of little valuein differentiating rheumatoid spondylitis from other spinal conditions. When,however, the protein content was elevated above 100 mg. per 100 cc., someother cause should be sought, even though spondylitis wasalso present.
8. The use of penicillin in the treatment of agranulocytosis-reportof a study resulting from chrysotherapy in rheumatoid arthritis.
9. The management of chronic arthritis and other rheumaticdiseases among soldiers in the U.S. Army.
10. Precipitating and predisposing factors in rheumatoidarthritis among soldiers.
11. The incidence of rheumatic diseases among soldiers-astudy of 6,000 cases at an Army rheumatism center.
12. Roentgen therapy in the treatment of rheumatoidspondylitis.31 Although roentgen therapy had been administered forrheumatoid spondylitis, there was considerable doubt about its efficacy. Thisstudy was designed as a blind triple crossover to determine the benefit of X-raytherapy. Twenty-five patients received roentgen therapy to the area (one ormore courses) of the spine clinically involved over a period of 6 months. Asecond group of 25 patients were exposed to the roentgentherapy equipment but no roentgen rays on one or moreoccasions for 6 months. The third group of 25 received physical therapy. Allreceived salicylates as needed. Between the sixth and the ninth months, thegroups were crossed over. At the end of 9 months, all had received one or morecourses 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 roentgentherapy.32
13. Post-gonorrheal rheumatoid arthritis.
Ashburn General Hospital functioned as a rheumatism centerfor 15 months and 18 days, beginning on 1 September 1944. It was declaredsurplus on 12 December 1945. All patients were disposed of by 18 December1945.
The officers assigned to the section on rheumatic diseaseshad very fine opportunities to study these conditions in all theirmanifestations. Despite the limited time this center was in operation, varioustypes 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, December 1946.
32Roentgen therapy became the treatment of choice for rheumatoid spondylitis until 1954, when the question was raised of a possible increase in the incidence of blood dyscrasia occurring in patients with rheumatoid spondylitis who had received X-ray therapy. This has not been resolved to the present.-R. T. S.
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1. Arthritis resembling Reiter's syndrome.33
2. The penetration of penicillin into joint fluid followingintramuscular administration.34
3. The effect of Prostigmine (neostigmine) onthe muscle spasm in rheumatoid arthritis.35
4. The diagnosis and treatment of Reiter's syndrome.36
5. Gold therapy in the treatment of rheumatoidarthritis. Only 21 patients were considered suitable for gold therapy before theinvestigation was summarily terminated by the closure of the center.
Although chrysotherapy enjoyed a measure of popularity incivilian medical circles, it had not been an approved method of treatment in therheumatism centers. Approval was lacking because of (1) the prolonged period ofweekly injections required (up to 24 or more) ; (2) thegeneral belief that gold was highly toxic; and (3)the lack of definite evidence to show that gold wascapable of producing remissions of the disease.
The possible benefits which might be achieved with goldtherapy in 1945 were severely limited by the fear of the severe toxic effects ofagranulocytosis, exfoliative dermatitis, and renal damage, particularly sincethere was no known antidote for gold. Consequently, treatment programswere arbitrarily limited to 20 to 24 weekly injections; toan overall total dosage of 800 to 1,000 mg. of the drug; or were administered incourses with rest periods without gold following each remission. Theselimitations produced an unspectacular remission rate of approximately 35percent.
The discovery of the dramatic changes that could be producedin rheumatoid arthritis by ACTH and cortisone and its derivatives directed theattention of many rheumatologists from chrysotherapy. On the other hand,the beneficial effect of the adrenocorticosteroids in the treatment ofgold toxicity encouraged others. With the further revelation that BAL (Britishanti-lewisite)37 was a specific antidote for goldtoxicity, much of the stigma attached to gold was removed.
Investigators, no longer hampered by the arbitrary limitingof gold to a dose that produced the least toxicity in the greatest number ofpatients, began to increase the remission rate to as high as 65 percent by moreprolonged 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'sSyndrome; Observations on 25 Cases. J.A.M.A. 129: 593-595, 27 Oct. 1945.
34Balboni, V. G., Shapiro, I. M., and Kydd, D. M.:Penetration of Penicillin Into Joint FluidFollowing Intramuscular Administration. Am. J.M. Sc. 210: 558-591,November 1945.
35Balboni, V. G., Hollander, J. L., and Kydd, D. M.: TheEffect of Prostigmine (Neostigmine) on the Muscle Spasm in Rheumatoid Arthritis. Presented at American Rheumatism Association Annual Meeting, New York City, June1946.
36Hollander, J. L.: Diagnosis andTreatment of Reiter's Syndrome. M. Clin. North America 30: 716-723, May 1946.
37(1) Regan, C., and Boots, R. H.: Treatment of GoldDermatitides; Use of BAL. J.A.M.A. 133: 752-754, 15 Mar. 1947. (2) Cohen, A., Goldman, J., and Dubbs, A. W.: Treatment of Acute Gold and Arsenic Poisoning; Use of BAL. J.A.M.A. 133: 749-752, 15Mar. 1947. (3) Margolis, H. M., and Caplan, P. S.: BAL in Treatment of Toxicity From Gold. Ann. Int. Med. 27: 353-360, September 1947.
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gold and prolonged the remissions by giving a maintenance at2- to 4-week intervals for months to years.38
SUMMARY
Of the more than 500,000 patients with rheumatic diseasesadmitted to hospitals between the years 1942-45, lessthan 20,000 of them were transferred to the arthritis centers at the Army andNavy General Hospital and Ashburn General Hospital. As had been recommendedoriginally, not all patients were to be sent to the centers because those withacute and short-lived situations could be treated locally. Only those with thepossibility of a need for prolonged treatment or diagnostic problems wereconsidered eligible for admission to these hospitals. Even among those patientswho were considered to be poor risks, approximately 45 percent couldbe returned to some type of military duty. The need for rheumatism centershas been well established from the experience in World War II.
It is conceivable that a greater conservation of manpowerwould be possible among military personnel with rheumatic diseases. Specificdiagnosis at an earlier hospitalization could permiteffective treatment and decrease the need for evacuationto the Zone of Interior. This would be particularly true ofthe second most common rheumatic condition, psychogenicrheumatism. Immediate recognition would permit adequatepsychiatric therapy to prevent this conversion state frombecoming a fixed disability.
Provision should be made in all theaters of operations tohave at least one officer, trained in the care of rheumatic diseases, on themedical staff of each hospital facility. He would beresponsible for making a prompt diagnosis, initiating therapy in all patients,and determining whether they could be treated there andreturned to duty or would require more prolonged treatment and should,therefore, be evacuated.
Special rheumatic disease centers should also be availablefor the care of chronic rheumatic diseases and to handle diagnostic problems.Conservation of military manpower should continue to be an importantconsideration in these centers. An additional responsibility should be assigned;namely, conservation of civilian manpower for those patients where there is nopossibility of further military duty. These centers should be staffed as fullyas possible with well-trained rheumatologists, employing the latest refinementsin the treatment of rheumatic diseases. Even more emphasis should be placed onclinical investigations which, carried out in the largest facilities of theirtype in the world, under the supervision of the top experts in our Nation, couldlead to greater conservation of manpower.
38Finally, in 1958, a remission rate of 82 percent wasachieved by gradually increasing the weekly doses of gold in those patients whofailed 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., andGoldman, M.: Increasing the Effectiveness of Gold Therapy inRheumatoid Arthritis. J.A.M.A. 167: 1197-1204, 5 July 1958.
