Ann Rheum Dis: first published as 10.1136/ard.5.4.106 on 1 June 1946. Downloaded from THE MANAGEMENT OF CHRONIC ARTHRITIS AND OTHER RHEUMATIC DISEASES AMONG SOLDIERS OF THE UNITED STATES ARMY* BY PHILIP S. HENCH, -M. C. (Colonel, Army of the U.S.) t and EDWARD W. BOLAND, M. C. (Major, Army of the U.S.)< During the First World War about 93,000 in 1943-twenty-five years after the war-the American soldiers developed some sort of " rheu- Veterans' Administration was expending annually matism." 1 Four common rheumatic diseases- $2,500,000 in pensions alone to soldiers of World rheumatoid arthritis, rheumatic fever, osteo-arthritis, War I with rheumatic heart disease.3 and muscular rheumatism-accounted for about 80% of these cases (Table 1). The subsequent Need for Rheumatism Centres During the First World War no special rheumatism TABLE 1.-INCIDENCE OF CERTAINT DISEASES IN THE UNITED STATES centre was officially established by the War Depart- ARMY, FIRST WORLD WAR (April 1, 1917, to Dec. 31, 1919) ment. However, Major Ralph Pemberton and his Total of Mean Annual Strengths for the War Period-4,128,479 associates were afforded the opportunity of studying Soldiers carefully at United States General Hospital Number 9, Lakewood, New Jersey, 400 cases of Condition Total Percentage Rates per chronic arthritis among soldiers.4 "Although Cases ge1,000 soldiers General Hospital Number 9 was never designated Arthritis (rheumatoid and 33,613 36 8 14 as a ' centre,' it functioned as one." osteo-arthritis). During World War I the mean strength of the Acutearticularrheumatismn 24,770 27 6 00 American Army over a period of two and three- (rheumatic fever). quarter years (33 months: 1, April 1917, to Decem- http://ard.bmj.com/ "Muscular rheumatism " 12,093 13 2 93 ber 31, 1919) was 4,128,479. Thus, during every Gonorrhoeal arthritis 7,895 9 1.91 month of that war an average of 2,807 soldiers " Myositis" § .. .. 4,135 4 1 00 developed rheumatism. If the incidence rate for " Synovitis" § .. 3,665 4 *87 rheumatic diseases" among soldiers during that war (22-4 cases per 1,000 soldiers) were main- " Tenosynovitis" § 2,671 3 65 tained during this second world conflict, the War " Ankylosis of joints" § 1,907 2 *46 Department could expect that, out of an army of " Otherdiseasesofjoints 1,614 2 39 8,000,000 soldiers, there would develop within the on September 29, 2021 by guest. Protected copyright. (non-traumatic). first two and three-quarter years of this war (namely, Tuberculous arthritis 188 - 05 between December, 1941, and August, 1944, Gouty arthritis .. 82 - 02 inclusive) about 180,000 cases of rheumatism-an Total 92.633 100 22 43 average of about 5,454 cases during every month of the war. Of these 180,000 cases, about 64,000 cases would be of chronic rheumatoid arthritis or cost to the government of these 92,633 cases of of osteo-arthritis. (The figures for this war are not rheumatism has never been estimated; it mLIst have yet available.) To prepare for such a possibility, been very great. In 1931, thirteen years after the the Surgeon-General and his Associates, with the war, the Veterans' Administration was paying over co-operation of the American Rheumatism Associa- $10,000,000 a year in disability compensations to tion, took, in the fall of 1942, the first tentative steps about 35,000 ex-Servicemen with " arthritis," 2 and toward the subsequent establishment of one or more rheumatism centres for the Army if or when * From the Rheumatism Centre, Army and Navy General Hospital, the need materialized.6 To date the need has been Hot Springs, Arkansas. such that five rheumatism centres have been estab- t Director of the Rheumatism Centre and Chief of the Medical Service (now returned to the Mayo Clinic, Rochester, Minnesota). lished-two for patients with chronic rheumatic I Chief of the Section on Rheumatic Diseases (now returned to diseases, and three for patients with rheumatic Los Angeles, California). "' jI In addition to the 24,770 cases of acute articular rheumatism fever. (rheumatic fever), there were 17,372 cases of " valvular heart disease," the great majority of which were probably rheumatic in origin. § These conditions were not fully defined in the original reference; Three rheumatism centres were recently established for the joint the terms are those used in the Manual of the International List of Services (Navy, Army, Air Force) of the Canadian Government: one Causes of Death, Second Revision, Paris, 1909; Washington, D.C., at St. Thomas, Ontario, opened in June, 1945; others at Winnipeg Government Printing Office. 1913. and at Nanaimo, B.C., opened in April, 1945. 106 Ann Rheum Dis: first published as 10.1136/ard.5.4.106 on 1 June 1946. Downloaded from RHEUMATIC DISEASE IN U.S. SOLDIERS 107 The Rheumatism Centre of the United States Army at the Army and Navy General Hospital; the main building (left) is now connected with the Eastman Annex (right). PURPOSES OF A CENTRE centre for the diagnosis and treatment of rheumatic The majority of soldiers who develop rheu- diseases.8 This hospital, the Army's oldest general matism need not be transferred to special centres. hospital, was chosen because of its past history and excellent facilities. Because of the hot Patients with transient muscular rheumatism, mild adjacent http://ard.bmj.com/ rheumatic fever without carditis, or acute traumatic springs, this hospital has, since 1887, been a mecca or specific infectious arthritis can be handled for the rheumatic personnel of the Army. In 1933 effectively in the adjacent station or regional hospital. the old main hospital building was demolished and Rheumatism centres are designed for the care of replaced by a large new building, and in 1943 an difficult or progressive cases, or for diagnostic adjacent large hotel was acquired, renovated, and problems.7 connected to the main building, thus creating a The chief aims of a rheumatism centre are these: capacity of 1,342 hospital beds with an additional 1. Accur ate diagnosis.-To provide a diagnostic 383 beds for patients being reconditioned (total on September 29, 2021 by guest. Protected copyright. centre where difficult cases can be studied by special 1,725 beds). methods and by medical officers with a special know- ledge of rheumatic diseases. A proper knowledge of rheumatic diseases 2. Intensive treatment. To provide special facilities demands familiarity with all phases of general for the treatment of the more severe or progressive medicine. The productive record of American and cases. European hospitals which have been devoted 3. Prompt disposition. To accomplish as great a exclusively to the study of rheumatic diseases has reduction in hospitalization-time as is consistent with ,adequate treatment. often been disappointing. Rheumatism clinics 4. Increased salvage. To restore to duty, if possible, and services in civilian hospitals maintain their more men with " cured " or " arrested " disease. vitality by, and derive much of their inspiration 5. Rehabilitation. To educate and rehabilitate for from, their close association with the other clinical civilian life those whose disability necessitates discharge and laboratory departments. Therefore, one of the from the Army. chief advantages of this rheumatism centre is its 6. Application of newer advances in treatment. 7. Appropriate clinical studies ofpatients while under placement in a large general hospital with its varied treatment. medical and surgical specialties. Thus the rheu- 8. Long-range economy. An incidental, but im- matic patient commands the services of specialists portant aim is to reduce the costly need for disability in many fields. pensions and prolonged hospitalization in Veterans' Facilities. The rapid growth of the centre is shown by the daily census of the section on rheumatic diseases, CENTRE AT THE ARMY AND NAVY GENERAL HOSPITAL which increased from 56 patients present on a given On Dec. 17, 1943, the Surgeon-General designated day in January, 1944, to 704 patients actually present the Army and Navy General Hospital as the first on a given day in October, 1944. During the year Ann Rheum Dis: first published as 10.1136/ard.5.4.106 on 1 June 1946. Downloaded from 108 ANNALS OF THE RHEUMATIC DISEASES 1944, 3,105 " rheumatic patients " were admitted, convalescence and reconditioning, but not of course and, between January and June, 1945, inclusive, during the acute phase of the disease. 2,210 additional "rheumatic patients" were ad- The policies of the War Department regarding mitted-a total of 5,315 in 18 months. Many of disposition of such cases are flexible, not static. In the patients have been received from various camps general, the following patients have been discharged throughout the country, but during recent months rather promptly from service: those with prolonged most of the patients have come from overseas active rheumatic fever, those with frequent recur- hospitals. The majority have come by boat from rences, and those with significant cardiac involve- the South Pacific or from the European theatre ment. But some patients in the last category who of operations, but many have come via the possessed unusual technical skills or other military ambulance planes of the Air Transport Command. qualifications have been retained on limited service The speed of evacuation of certain rheumatic if their cardiac lesions were well compensated. patients from overseas has often been startling; Most of the 900 patients admitted to these three some have arrived here by plane 4 to 6 days after centres have been or will be returned to temporary leaving South Pacific hospitals (e.g. 4 days from limited duty for six months in a warm dry climate. Saipan to Hot Springs); others have arrived within Thereafter, re-examination and final disposition 3 to 7 days from England, Italy, or France (e.g.