Portal de Periódicos da CAPES

Rheumatology Practice at Mayo Clinic: The First 40 Years–1920 to 1960

2010; Elsevier BV; Volume: 85; Issue: 4 Linguagem: Inglês

10.4065/mcp.2009.0701

1942-5546

Gene G. Hunder, Eric L. Matteson,

Historical Medical Research and Treatments

In its early years, Mayo Clinic had primarily a surgical practice. Patients with musculoskeletal complaints were cared for by one of the Mayo brothers (Dr William J. Mayo or Dr Charles H. Mayo) or their initial partners. That such patients were seen in Rochester, MN, is evidenced by a report the brothers wrote in 1895 that described surgical treatment of a patient with knee sepsis.1Mayo CH Mayo WJ Acute suppuration of the knee joint: treatment by transverse anterior incision, partial dislocation and gauze packing.Ann Surg. 1895; 21: 37Crossref Google Scholar, 2Clapesattle H The Doctors Mayo. 1st ed. University of Minnesota Press, Minneapolis, MN1941: 822Google Scholar A second article on this topic appeared 2 years later.3Mayo CH Septic diseases of the knee-joint.JAMA. 1897; 28: 542-544Crossref Scopus (1) Google Scholar In 1910, Dr Melvin S. Henderson was appointed to develop a Section of Orthopedics. To gain experience and become acquainted with the best orthopedic practices of the day, Henderson visited a number of leading orthopedists in the United States and was sent by the Drs Mayo to visit centers in Great Britain in 1911 and 1912. Dr Henry W. Meyerding joined Henderson in 1911.4Morrey BF Orthopedic Surgery at the Mayo Clinic. Mayo Clinic, Rochester, MN1999: 242Google Scholar Patients with bone and joint problems were then seen by Henderson and Meyerding. The first nonsurgical physicians who joined Mayo Clinic functioned mainly to screen patients for surgery and participate in postoperative management (G. Eusterman, MD. My experience at the Mayo Clinic. Unpublished manuscript, 1956). As Mayo Clinic grew in size and reputation in the early part of the 20th century, the patient population evolved. Increasing numbers of patients were referred to Rochester or arrived on their own with a broad variety of illnesses, some not amenable to surgery. Thus, the need to diagnose and manage nonsurgical conditions continued to expand, and physicians with an interest in medical diseases were recruited. Additionally, hospital beds were dedicated to nonsurgical patients, initially in 1917 (G. Eusterman, MD). Progress in medicine has evolved gradually throughout history. Even though a specific date can be provided for a new discovery, time is often required to confirm this finding and disseminate the advance to others. In the current report, we have attempted to determine when a medication, method, or practice was actually used rather than when it was first described. We have divided the history into 3 periods, which are general timelines rather than strict demarcations. Mayo Clinic grew markedly during the 40 years between 1920 and 1960. In 1920 there were 62 medical staff members, and in 1960 there were 348. Dr Phillip S. Hench, who became the first rheumatologist at Mayo Clinic, arrived in Rochester in October 1921 for training in medicine and surgery after graduating from the University of Pittsburgh Medical School in 1920.5Physicians of the Mayo Clinic and the Mayo Foundation. University of Minnesota Press, Minneapolis, MN1937Google Scholar He later stated that for a time he was the only resident primarily interested in training in internal medicine at Mayo Clinic.6Hench PS A reminiscence of certain events before, during and after the discovery of cortisone.Minn Med. 1953; 36: 705-710PubMed Google Scholar In 1923, Hench was appointed as a first assistant in the Section of Medicine, headed by Dr Leonard Rowntree.5Physicians of the Mayo Clinic and the Mayo Foundation. University of Minnesota Press, Minneapolis, MN1937Google Scholar Dr William Mayo suggested that Hench focus his interest on patients with arthritis, to which he agreed (C. H. Slocumb, MD. Rheumatology at the Mayo Clinic 1926-1951. Unpublished manuscript, 1951). Hench's initial assignment was working with the Section of Orthopedics to examine and treat patients with nonsurgical musculoskeletal conditions. In January 1926, Hench was appointed as an associate in the Rowntree Section of Medicine with a joint appointment in the Section of Orthopedics to head a new service at Saint Marys Hospital for patients with chronic arthritis (C. H. Slocumb; P. S. Hench, MD, Mayo Historical Files, Unpublished). The new rheumatology service was established on Third Center Medical of the original Saint Marys Hospital built in 1889 (Sr M. Pantaleon, OSF. Organization of arthritic nursing services at Saint Marys Hospital, Rochester, MN. Unpublished manuscript, 1958) (Figure 1). The original hospital facilities were multiple bed wards (Figure 2). There were no modern conveniences in the original unit. Nurses walked down a long corridor to the utility room to bring water to bathe the patients. There was no separate examining room, and thus examinations were performed at the bedside. Initially, the only space available for physical therapy was a small room on the fifth floor. The room was too small to treat all patients, and on many occasions therapists carried out the exercises at the bedside (Sr M. Pantaleon, OSF).FIGURE 2Saint Marys Hospital ward in the old hospital, which had been completed in 1889. This 5-bed ward was similar to the type of housing in the Rheumatology Service of the 1920s and 1930s.View Large Image Figure ViewerDownload (PPT) At first, most patients seen with serious nonsurgical joint problems were admitted to the hospital service, and the new service was busy from the beginning. In 1926 there were 574 admissions (P. S. Hench, MD. Report of the arthritis service for the year 1929. Unpublished report, 1929). In subsequent years, more patients were seen as outpatients to help reduce their expenses. However, the practiceof admitting patients with multiple swollen painful joints to the Rheumatology Service at Saint Marys Hospital for work-up, rest, and physical therapy continued for many years. This was especially true the first time patients visited Mayo Clinic or when they experienced a flare-up in symptoms. In the late 1920s, the census on the hospital service averaged 30 to 40 patients (E. B. Rentschler, MD. Letter to Dr Hench. Unpublished letter, 1958). One or two internal medicine fellows (Mayo Clinic terminology for postgratudate physicians-in-training) were assigned to the rheumatology hospital service each quarter. When available, a first assistant, defined as a fellow with advanced training who had already performed a rheumatology rotation and had added responsibility, was also assigned. To gain more experience Hench spent 6 months between October 1928 and May 1929 visiting rheumatologists in Europe, chiefly in Germany. While he was away, Dr Edwin B. Rentschler, who served as the initial first assistant, was in charge of the hospital service. In 1929, there were 348 admissions to the service and 2121 outpatient consultations, all seen by Hench and Rentschler. The Saint Marys Hospital service, which combined patient care, teaching, and clinical research, was the first academic rheumatology unit established in the United States.7Engleman EP The history of ACR: Before 1970.in: Pisetsky DS The ACR at 75: A Diamond Jubilee. John Wiley & Sons, Hoboken, NJ2009Google Scholar, 8Smyth CJ Freyberg RH McEwen C History of Rheumatology. Arthritis Foundation, Atlanta, GA1985Google Scholar For the first 10 years, Hench was the only Mayo staff member whose primary interest was in rheumatology. During that time he staffed the busy in-patient service at Saint Marys Hospital, consulted as requested on outpatients, and continued to work with orthopedic surgeons.9Hench P Jepson P Differential diagnosis and medical and orthopedic care of several different forms of chronic arthritis.Med Clin North Am. 1926; 10: 563-595Google Scholar, 10Henderson M Hench P Types and treatment of chronic arthritis.Minn Med. 1929; 12: 202-210Google Scholar From 1930 on, Hench's outpatient consulting office was located in the Vascular Section in the Plummer Building, which was completed in 1928 (N. Barker, MD. The history of the medical vascular section of the Mayo Clinic as recorded by Dr Nelson Barker, Unedited. Unpublished manuscript.) When Hench was away, Drs Barker and Edgar V. Allen of the Vascular Section took outpatient consultations for him, and a rheumatology first assistant was in charge of the hospital service (N. Barker, MD). After several years, Hench moved his outpatient office to the Orthopedic Section offices in the Plummer Building. Dr Charles H. Slocumb came to Mayo Clinic in October 1931, after graduating from the University of Minnesota Medical School, and was appointed to the staff in 1935. Thereafter, Slocumb and Hench rotated on the rheumatology hospital service. In 1932, Sr Mary Pantaleon was appointed head nurse on the rheumatology hospital service, a position she held for most of the next 25 years. She had worked on the service before this appointment and was knowledgeable and devoted to the care of patients with arthritis. Her interest and skills did much to make the hospital service successfuland a leading international center for the care of patients with arthritis throughout the years. The staff physician assigned to the hospital service was responsible for the care of all the patients on the service, regardless of who admitted the patient. He saw all the patients each morning, accompanied by the fellows on the service. Usually 2 internal medicine fellows were assigned to the hospital service and rotated call daily for work-up of new admissions. In later years, as Mayo Clinic became larger and trained more physicians, 3 internal medicine fellows were assigned to each hospital service. The fellow who admitted the patient was then responsible to monitor that patient during hospitalization. On morning rounds, the fellow assigned the day before presented the new patients to the consultant (Mayo Clinic terminology for a tenured staff physician) and others at attending rounds and suggested further tests or treatments, as needed. After the new patients were examined, rounds were made on the other patients, and updates were provided on the status of the patients. The fellows not on call for the day saw their patients in the afternoon and notified the on-call fellow of any potential problems or pending issues; they also were expected to read and study about the illnesses of their patients and rheumatology in general. The on-call physician saw all patients again in the evening and responded to any problems that occurred during the night. The consultant was available at night by telephone. During the Great Depression, the number of patients admitted to Saint Marys Hospital service decreased. In 1930, 413 patients were admitted to the hospital service, but in 1933 the number was down to 150. By 1939, the number had risen progressively to 312. Similarly, in the early 1930s, the physicians on the hospital service were reduced to Hench or Slocumb and one fellow without a first assistant. The outpatient practice also decreased during the depression: from 2009 outpatient consultations in 1930 to 1174, the lowest, in 1932. During these times, Hench provided inpatient care in the mornings, performed outpatient consultations in the afternoons, and was also assigned to other general medical patient care duties. By 1939, with 2 staff, the outpatient consultations had increased to 3873. During the first decades of the 20th century, the understanding of rheumatic diseases was rudimentary. As a result, it was not uncommon to classify most patients with chronic musculoskeletal conditions as having variants of a single pathologic process. Acutely infected joints with specific organisms such as staphylococci and tubercule bacilli were recognizable and separately categorized, as were gout, neuropathic arthropathy, and pulmonary osteoarthropathy. Cases of chronic swelling of multiple joints with no knowncause were sometimes grouped together as "chronic polyarthritis" or "arthritis deformans."11Hench PS The systemic nature of chronic infectious arthritis.Atlantic Med J. 1925; 28: 425-436Google Scholar Rheumatoid Arthritis. In the 1920s, rheumatoid arthritis was called chronic infectious arthritis. Other terms for rheumatoid arthritis used by various authors included proliferative arthritis and atrophic arthritis (Table 1).10Henderson M Hench P Types and treatment of chronic arthritis.Minn Med. 1929; 12: 202-210Google Scholar The idea that this disease was caused by a chronic infection was based on reports first by workers in Europe in the late 1800s, who found microbes in blood and joints from patients with various forms of arthritis.12Hench PS Is Rheumatoid (Atrophic) Arthritis a Disease of Microbic Origin? Oxford University Press, London, England1938: 338Google Scholar In the United States, the report by Cecil et al13Cecil RL Nicholls EE Stainsby WJ Bacteriology of blood and joints in chronic infectious arthritis.Arch Intern Med. 1929; 43: 571-605Crossref Scopus (9) Google Scholar provided much evidence to support this theory. Using special culture techniques, they recovered streptococci from the blood of 62% of patients and the joints from 67% of patients with chronic infectious arthritis. In addition, antibodies to streptococci were found in blood. Other investigators found similar results.TABLE 1Terms Used for Rheumatoid Arthritis, Osteoarthritis, and Ankylosing Spondylitis Between 1920 and 1960 Rheumatoid arthritis Arthritis deformansChronic infectious arthritisChronic infectious (atrophic) arthritisAtrophic arthritisProliferative arthritisOsteoarthritis Senescent arthritisHypertrophic arthritisOsteoarthritisDegenerative joint diseaseDegenerative arthritisAnkylosing spondylitis Marie-Strumpell diseaseBechterew diseaseAtrophic spondylitisRheumatoid spondylitis Open table in a new tab As time went by, more investigators were unable to identify bacteria in blood and joints from similar patients; it was suggested that earlier findings were due to contaminants,14Bernhardt H Hench P Bacteriology of the blood in chronic infectious arthritis.J Infect Dis. 1931; 49: 489-496Crossref Scopus (3) Google Scholar and a second variant of the chronic infection idea was advanced. This hypothesis held that toxins liberated from extra joint foci of infection caused the arthritis or, alternatively, an allergy developed to the released bacterial products and caused the arthritis.12Hench PS Is Rheumatoid (Atrophic) Arthritis a Disease of Microbic Origin? Oxford University Press, London, England1938: 338Google Scholar Arthritis seen in patients with psoriasis and inflammatory bowel disease was suspected to have a similar pathogenesis.10Henderson M Hench P Types and treatment of chronic arthritis.Minn Med. 1929; 12: 202-210Google Scholar In the 1920s, basic treatment at Mayo Clinic for patients with chronic arthritis (probably both chronic infectious arthritis and polyarticular osteoarthritis) included a well-balanced diet, rest, and physical therapy (Table 2).11Hench PS The systemic nature of chronic infectious arthritis.Atlantic Med J. 1925; 28: 425-436Google Scholar, 15Hench P The protean manifestations of chronic infectious arthritis (with a note on treatment).Med Clin North Am. 1925; 8: 1295-1306Google Scholar Patients with disabling arthritis were admitted to the hospital service for evaluation and initiation of therapy. They were carefully examined for foci of infection. Tonsillectomies were performed when the tonsils were enlarged or looked infected, devitalized teeth were removed, the uterine cervix was cauterized in women, and the prostate was massaged in men, although it was already recognized that improvement did not always result (C. H. Slocumb, MD).9Hench P Jepson P Differential diagnosis and medical and orthopedic care of several different forms of chronic arthritis.Med Clin North Am. 1926; 10: 563-595Google Scholar, 15Hench P The protean manifestations of chronic infectious arthritis (with a note on treatment).Med Clin North Am. 1925; 8: 1295-1306Google ScholarTABLE 2Treatment of Rheumatoid Arthritis Between 1920 and 1960EraTreatment1920–1940 Bed restBalanced dietPhysical therapyPatient educationSalicylates, cinchophen, aminopyrineEliminate foci of infectionVaccine therapyFever therapySynovectomy1940–1950 Bed restBalanced dietPhysical therapyPatient educationSalicylatesVitaminsGold therapy1950–1960 Bed restBalanced dietExercise, heat, massagePatient educationSalicylatesCortisone, ACTH (adrenocorticotropic hormone)Gold therapyHydrocortisone joint injections Open table in a new tab Physical therapy was considered important. Exercises were aimed at improving the range of motion of affected joints, strengthening muscles, and preventing deformities.15Hench P The protean manifestations of chronic infectious arthritis (with a note on treatment).Med Clin North Am. 1925; 8: 1295-1306Google Scholar Heat and massage were used to improve circulation in the affected areas in an attempt to enhance removal of toxins and infection debris.10Henderson M Hench P Types and treatment of chronic arthritis.Minn Med. 1929; 12: 202-210Google Scholar Joint bracing and progressive casting were used to support joints and reduce contractions, especially of the knees. Canes and shoe corrections were prescribed. In some cases of chronic arthritis of the knees, synovectomy was performed.10Henderson M Hench P Types and treatment of chronic arthritis.Minn Med. 1929; 12: 202-210Google Scholar Single badly damaged joints were sometimes surgically fused. Analgesics, including aspirin, sodium salicylate, cinchophen, and aminopyrine, were prescribed but were not considered a major aspect of therapy. In the 1920s, dilute hydrochloric acid was given orally if gastric analysis showed low acid content (C. H. Slocumb, MD). Fowler's solution (which contained potassium arsenate) was administered to some patients as a general tonic. By the early 1930s, these last 2 agents were no longer prescribed. Weekly educational sessions that covered the nature of arthritis and treatments as then understood were held for patients and relatives.15Hench P The protean manifestations of chronic infectious arthritis (with a note on treatment).Med Clin North Am. 1925; 8: 1295-1306Google Scholar Nonspecific vaccine (protein) therapy had been introduced as a treatment in 1916 and was increasingly used in many centers during the following decade.16Miller JL Lusk FB The treatment of arthritis by intravenous injection of foreign protein.JAMA. 1916; 66: 1756Crossref Scopus (2) Google Scholar The vaccines became available through state boards of health, the US Army, and pharmaceutical companies. In addition, a number of practitioners developed their own vaccines from bacteria originally cultured from tonsils or other body sources from patients with arthritis. It was thought that using a vaccine made from cultures taken from one or more patients with chronic arthritis might be more effective because the bacteria could be directly related to the disease. A variety of bacteria were used, including strains of typhoid, staphylococci, streptococci, and others. Vaccine therapy was used frequently at Mayo Clinic. By 1932, Hench noted that about 2500 patients had been treated with vaccine injections.17Hench PS Usual and unusual reactions to protein (fever) therapy.Arch Intern Med. 1932; 49: 1-25Crossref Scopus (3) Google Scholar Approximately 1500 of these patients were on the arthritis service; 1000 patients had different conditions and were on the vascular and other services. Although many US physicians used vaccines for all types of arthritis, the Rheumatology Section at Mayo Clinic used vaccines primarily for chronic infectious arthritis. The vaccine used at Mayo Clinic was a commercial triple typhoid vaccine made from 3 strains of killed bacteria. The vaccine was usually given intravenously.17Hench PS Usual and unusual reactions to protein (fever) therapy.Arch Intern Med. 1932; 49: 1-25Crossref Scopus (3) Google Scholar A prodromal period followed the injection, during which the patient might experience chills. Three to 5 hours after the injection, fever developed, and patients often experienced malaise, headache, gastrointestinal upset, and increased musculoskeletal pain. The temperature reached a maximum of 39° to 40°C and subsided within 6 to 12 hours. A period of euphoria and reduced joint pains often followed for varying time frames.17Hench PS Usual and unusual reactions to protein (fever) therapy.Arch Intern Med. 1932; 49: 1-25Crossref Scopus (3) Google Scholar Serious adverse reactions occurred, even death, but were considered uncommon. If the adverse reaction was acute and thought to be an anaphylactic reaction, epinephrine was given. If tolerated and helpful, a series of injections was given about twice a week for 6 to 10 injections. A second series could be given again after several weeks. Few if any reports on vaccine therapy contained detailed objective assessments of its effects. Vaccine use at Mayo Clinic declined toward the end of the 1930s, and eventually vaccines were no longer used.18Hench PS Bauer W Ghrist D et al.The present status of rheumatism and arthritis: review of American and English literature for 1936.Ann Intern Med. 1938; 11: 1089-1247Google Scholar One idea of the mechanism of action causing improvement in symptoms was that the vaccines desensitized patients to bacteria that might be responsible for the disease.19Miller SR An appraisal of the value of vaccine therapy in chronic arthritis.South Med J. 1933; 26: 583-589Crossref Scopus (1) Google Scholar Another idea in retrospect was that the temporary improvement was an endogenous corticosteroid mediated event secondary to the stress of the vaccine injection (L. E. Ward, MD, oral communication, 2009). During the 1920s, surgical sympathectomy was performed in selected patients with chronic infectious arthritis.20Rowntree LG Adson AW Bilateral lumbar sympathetic gangionectoly and ramisectomy for polyarthritis of the lower extremities.JAMA. 1927; 88: 694-696Crossref Scopus (3) Google Scholar, 21Rowntree L Adson A Hench P Preliminary results of resection of sympathetic ganglia and trunks in seventeen cases of chronic "infectious" arthritis.Ann Intern Med. 1930; 4: 447-454Google Scholar, 22Ghrist DG Hench PS The course and prognosis in chronic infectious arthritis: a study of relapses.Med Clin North Am. 1930; 13: 1499-1518Google Scholar The rationale for this procedure was based on the theory that development of arthritis was influenced by a neurogenic defect that limited the circulation to involved joints. This defect was corrected, at least in part, by sympathectomy. Patients considered the most suitable for sympathectomy were young individuals with rapidly progressive arthritis. Good candidates demonstrated alterations in vasomotor activity evidenced by cold, clammy, sweaty hands and feet. Sympathectomy was also performed in patients with scleroderma and Raynaud phenomenon in an effort to improve circulation to involved areas.23Hench PS Henderson MS Rowntree LG Adson AW The treatment of chronic "infectious" arthritis by sympathetic ganglionectomy and trunk resection.J Lab Clin Med. 1930; 15: 1247-1256Google Scholar The results were not uniform, and in the 1930s sympathectomy was limited to patients with scleroderma with Raynaud phenomenon and hypertension (L. E. Ward, MD, oral communication, 2009; C. H. Slocumb, MD).24Hench PS Craig WM Sympathetic ganglionectomy and ramisectomy for chronic infectious arthritis: aclinical interpretation.South Med J. 1931; 24: 636-645Crossref Scopus (2) Google Scholar Fever therapy for arthritis was introduced in the early 1930s. The use of fever in the treatment of syphilis led to its trial in other infections, or conditions suspected of being infectious. The rationale was that an elevated temperature that killed microorganisms was tolerated by humans.25Schamberg JF Tseng HW Experiments on the therapeutic value of hot baths, with speicial reference to the treatment of syphilis: physiologic observations.Am J Syph Gonorrhea Vener Dis. 1927; 11: 337-397Google Scholar, 26Simpson WM Artificial fever therapy of syphilis.JAMA. 1935; 105: 2132-2140Crossref Scopus (5) Google Scholar, 27Carpenter CM Warren SL Artificially induced fever in the treatment of disease.N Y State J Med. 1932; 23: 997-1001Google Scholar The suspected relationship of an infection, most likely streptococcal, was an important reason to try fever therapy for chronic atrophic arthritis, even though it became known that body temperatures achieved by fever therapy did not kill typical streptococci. Other possible effects included a direct bacteriostatic effect of the heat, augmentation or mobilization of antibodies against the suspected infecting organism, vasodilation that increased the blood supply to the joints and helped the body suppress the inflammation, and a general heightened metabolism caused by the fever, which was unfavorable to the suspected bacteria. In 1931, fever therapy for chronic infectious (atrophic) arthritis was reported as effective in a small number cases and was adopted during the next few years by a number of centers in the United States and elsewhere.28Markson DE Osborne SL The treatment of arthritis by sustained fever therapy: a preliminary report of six cases.Ill Med J. 1931; 60: 397-403Google Scholar, 29Hench PS Slocumb CH Popp WC Fever therapy: results for gonorrheal arthritis, chronic infectious (atrophic) arthritis, and other forms of "rheumatism.".JAMA. 1935; 104: 1779-1790Crossref Scopus (5) Google Scholar At Mayo Clinic, fever was induced by the Kettering hypertherm cabinet, which used electric coils and gently circulated humidified air (Figure 3).29Hench PS Slocumb CH Popp WC Fever therapy: results for gonorrheal arthritis, chronic infectious (atrophic) arthritis, and other forms of "rheumatism.".JAMA. 1935; 104: 1779-1790Crossref Scopus (5) Google Scholar The cabinet enclosed the patient in a supine position except for the head. Small sliding doors on the sides of the cabinet allowed access so that the physician or nurse could adjust protective blankets and measure blood pressure and temperature. After an hour's treatment, the patient's temperature was generally at the desired level of 40° to 41°C, and then the hypertherm was adjusted to maintain the body temperature at the desired level for about 5 hours. Patients were encouraged to sip iced 0.6 percent saline solution during treatment to prevent salt depletion. About 10% of patients with chronic atrophic arthritis were unable to endure the sessions of fever.30Hench PS Bauer W Fletcher AA Ghrist D Hall F White TP The present status of the problem of "rheumatism": a review of recent American and English literature on "rheumatism" and arthritis.Ann Intern Med. 1935; 8: 1315-1374Google Scholar If the treatment was helpful, a session of fever therapy was performed twice a week for 6 to 8 treatments. A second course could be given after an interval of 2 to 3 months. Hench reviewed the Mayo Clinic results of treatment in 60 patients withchronic infectious (atrophic) arthritis in 1936. None became symptom free, but 20% had "notable improvement," 20% were moderately relieved, and the others showed no improvement.31Hench PS The present status of fever therapy in the treatment of gonorrheal arthritis, chronic infectious (atrophic) arthritis, and other forms of "rheumatism.".J Lab Clin Med. 1936; 21: 524-531Google Scholar The best results were obtained in patients whose duration of symptoms was less than 1 year. Any improvement tended to be of short duration. Other rheumatologists reported similar experiences. The failure to produce sustained improvement led to less use, and by the end of the 1930s fever therapy was seldom used except in occasional cases of reactive arthritis (L. E. Ward, MD, oral communication, 2009).18Hench PS Bauer W Ghrist D et al.The present status of rheumatism and arthritis: review of American and English literature for 1936.Ann Intern Med. 1938; 11: 1089-1247Google Scholar, 31Hench PS The present status of fever therapy in the treatment of gonorrheal arthritis, chronic infectious (atrophic) arthritis, and other forms of "rheumatism.".J Lab Clin Med. 1936; 21: 524-531Google Scholar By the 1930s, when the theory of systemic infection as a cause of rheumatologic diseases faded, the term atrophic arthritis became preferred.14Bernhardt H Hench P Bacteriology of the blood in chronic infectious arthritis.J Infect Dis. 1931; 49: 489-496Crossref Scopus (3) Google Scholar, 32Hench PS Bauer W Fletcher AA Ghrist D Hall F White TP The present status of the problem of "rheumatism" and arthritis: review of American and English literature for 1934.Ann Intern Med. 1936; 9: 883-982Google Scholar Also, more attention was paid to the general condition of patients. Those unable to care for themselves adequately often became malnourished (C. H. Slocumb, MD). An appropriate diet was prescribed, and attempts were made to arrange assistance for the patient after dismissal from the hospital. After Dr Frank H. Krusen came to Mayo Clinic in 1935 to establish a Section of Physical Therapy, that part of treatment improved considerably.5Physicians of the Mayo Clinic and the Mayo Foundation. University of Minnesota Press, Minneapolis, MN1937Google Scholar Gold salt injections had first been used for arthritis in France in the late 1920s.33Forestier J Rheumatoid arthritis and its treatment by gold salts: the results of six years' experience.J Lab Clin Med. 1935; 20: 827-840Google Scholar Results appeared promising, and gold became used widely in Europe. Early results in the United States were not as encouraging. Toxicity was common, perhap