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 In the Beginning...
Whether Osler said, “When an arthritic walks in the front door, I walk out the back” is apocryphal is moot. The poignant fact is that in the first third of the last century
“cripples” had only two destinations, the chronic hospital or the back room.
Although the Koch revolution brought miraculous cures in some infectious diseases, repeated attempts to treat rheumatism as a bacterial infection were failures. Scientific symposia of the 1930s
were infarcted with papers on arthritis and gall bladder or bacterial digestive disorders. Vaccines that turned the tide of epidemics had little effect on joint diseases, even after intravenous
injections of vaccines of Streptococci or diphtheroids. Fever therapy gave only temporary relief and focal sepsis of the teeth as etiologic lost its magic, almost as quickly as patients lost
their teeth.
Hospitals were not interested in chronic disease, and the failure of the rheumatic disease branch of medicine, which was generally burgeoning in other fields, led many clinicians to joint efforts
to solve this problem. In Europe, the First International Congress on Physical Treatment in 1913 proposed setting up a Central Rheumatic Disease Board to attack the problem. This did not happen until
1925 with the founding of the International Committee on Rheumatism, by J. Fortescue Fox of London and, under his direction, the International League Against Rheumatism (ILAR) in 1928. Its initial
mission said, “The fight against rheumatic afflictions has to be put on a sound and scientific basis...”.
Fox influenced a number of centers, particularly the US Mayo Foundation, where Philip S. Hench attracted a small group of like-minded clinicians that coalesced into the American Committee Against
Rheumatism. It expanded into a wider organization in 1928 that included Hench, George Minot, Cyrus Sturgess, and A. Almon Fletcher of Toronto.
Dr. Fletcher graduated from the University of Toronto, joined the Number 4 Canadian General Hospital, and served in Greece. While there he became interested in the combination of intestinal
disorders and joint swellings. On return to Canada he joined the faculty of the University of Toronto. He was appointed by Professor of Medicine Duncan Graham to the diabetic ward and was one of the
clinicians, under Banting’s supervision, to inject the first doses of insulin. But he retained an interest in rheumatic disorders which became, later in life, his major work.
Fletcher and G. Douglas Taylor, a Montreal graduate, were active on the American medical scene. Taylor presented papers on roentgenological findings in arthritics1, while Fletcher discussed the
influence of dietetic factors, following a presentation by W. Paul Holbrook of Tucson on Management of Atrophic Arthritis.
The third annual meeting of the Association brought Lord Horder, GCVO, MD, FRCP, of the British Committee for the Study of Rheumatic Diseases, to Kansas City; he discussed his report to the
British government of the depth of the problem of different types of arthritis and the necessity that government take preventative measures2. On the same program Dr. Russell Cecil started a
discussion on criteria for diagnosis.
The following year the American organization renamed their group the American Rheumatism Association (ARA). The scientific meetings, lasting one day, provided opportunities for exchange of views
and knowledge.
Fletcher, who had the prestige of his association with Banting, was chosen by Hench to be an editor of Rheumatism Reviews.
The Horder presentation was “A Plan for National Action.” He reported the dismaying number of children in London with rheumatism and “in face of such tragic figures as these it
is difficult to understand why this problem of rheumatic disease has been long neglected.” His vivid description of the extent of disability and suffering energized the two Canadians in the
audience to create a similar organization and on return to Ontario, with the support of Walter Barnhart, Fletcher, Taylor and others established The Canadian Rheumatism Association (CRA). Fletcher
was elected President. The objectives were to act as a central clearing body on a national scale and to collect data pertaining to rheumatic disease. Taylor produced statistics on the degree of
involvement in chronic arthritis and was elected President in 1938-39 but activities came to a halt with the outbreak of World War 2.
One of the servicemen in the war was a young physician, J. Wallace Graham, who had graduated in University of Toronto Dentistry and Medicine in 1933. He interned with Fletcher and was chosen by
Duncan Graham to take postgraduate training in the UK. During his membership qualification in London he was examined by Horder. After a few years at the Toronto General Hospital, Graham joined the
Navy and was in charge of hospital wards for rheumatic diseases.
This serendipity of the Horder contact was replicated. When he flew back to Canada during the war, he became acquainted with a fellow passenger, Dr. Holbrook, who became President of the ARA.
By 1946 Graham had unique qualifications and a singular ability — to be in the right place, at the right time, with the right people. As President of the Canadian Rheumatism Disease
Association in June of 1947 he urged the Canadian Federal Government to “hold a conference to examine the problem of rheumatic diseases and the means to attack it.” The resolution was
given more impetus by the work of Mary Pack of Vancouver, a fervent, vigorous school teacher who had been arousing public interest to the plight of the rheumatoid patient. Although Dr. A.W. Bagnall
Sr., her rheumatoid mother’s physician, had pioneered gold treatment in Canada, in association with Dr. Dean Robinson of Banff, no one in government heard Pack’s cries for help. When
Bagnall was unable to attend the conference in Ottawa in 1948, he sent Pack.
The second pressure on Paul Martin, Minister of Health and Welfare, who presided at the conference was a strong letter received earlier from the world famous pathologist William Boyd, outlining
the urgent need for Ottawa to recognize the devastating state of the care of heart, cancer, and rheumatic sufferers.
Graham, Taylor, Fletcher, Pack and others gave convincing evidence at the conference with the result that the government approved the founding of the Canadian Arthritis and Rheumatism Society, a
voluntary health agency, to raise funds to support research, education, and treatment. Graham was elected President and T.C. Routley, Secretary General of the Canadian Medical Association, was on the
Board to promote the support of the national organization.
About the same time, the Arthritis and Rheumatism Foundation was established in the US with financier Floyd Odlum as President. Its mission was to raise funds to be used by the ARA to conduct
research and to hold the Seventh International Congress of Rheumatic Diseases in New York City. This brought two geographic associations —EULAR and PANLAR (and later SEAPAL) —
together.
The US groups prevailed upon Washington to pass the Omnibus Medical Research Act, which opened the door to government funding. CARS did not have that opportunity and resolved to rely on public
donations — frequently from families of arthritic patients. British Columbia led in raising money, chiefly by the presence of the Blue Birds — allied health workers who treated patients
in their home and thereby raised public awareness about arthritis.
Unfortunately groups in Canada could not tap grant funding as could their US counterparts, but by the grace of a gouty Board of Directors, funds and finesse began to flow to CARS. Graham’s
patient James A. Gairdner, a prominent business leader, was elected President; and an equally prominent Lou Wood was close to the Board.
Wood was also on the Board of the Canadian National Institute for the Blind, and in searching for an executive officer for CARS, the name of Edward Dunlop, MBE, GM, was put forward. Blinded during
the war from a hand grenade explosion, Dunlop was heading the Rehabilitation Department of the Department of Veterans’ Affairs and was especially qualified to become National Director of CARS
through his incisive administrative and planning skills. His appointment, coincidental with Horder’s approval of CARS recognition by the Empire Rheumatism Council, paved the way for the
template laid down by Graham, Dunlop and Fletcher for the future in “Arthritis — Plan for Attack.” The elements of the plan were increased facilities for diagnosis and treatment,
professional education, and research. CARS was to press forward the attack and a Medical Advisory Board was to prepare and approve projects. This forced, draft concept was fired by the euphoria
created by Philip Hench’s announcement of the success of cortisone (adrenocorticotropin hormone) at the 7th International Congress in June 19493. Graham, a friend of Hench, was reported by a
fellow passenger in a taxi returning to the hotel, as stating, “Well, at least there is still osteoarthritis.”
Although CARS lacked the panache given to the March of Dimes by F.D. Roosevelt, there was an alternate engine — the presence in the community of recognizable workers such as
physiotherapists, social workers, and physicians. This orientation was blueprinted by The Rheumatic Disease Unit (RDU) concept, prepared by M.A. Ogryzlo (who replaced the deceased Graham) as Director
of the University of Toronto RDU, D.A. Gordon, and H.A. Smythe and instituted in 1963. A network of units for the study and prolonged active treatment was to be established in all teaching hospitals
across Canada with all the necessary complementary disciplines. This concept was given additional weight through submissions to the Royal Commission on Health Services by Smythe and P.A. Platt in a
series of supplementary documents that looked at needs, ability, manpower and cost.
The work and planning with emphasis on research, teaching, community and outcome measurements by the pioneers resulted in dramatic change in the care of those afflicted with arthritis. But another
legacy is the greatly increased number of highly skilled physicians, basic scientists, allied health workers, and social workers that is evident today.
CHARLES M. GODFREY, CM, O ONT, MA, MD, FRCPC, DHMSA,
Emeritus Professor, University of Toronto,
317-484 Church St.,
Toronto, Canada M4Y 2C7
Address reprint requests to Dr. Godfrey.
ACKNOWLEDGMENT
I am grateful for the expert help and information given to me by Hugh Smythe in this condensed history.
REFERENCES
1.Taylor GD, et al. Roentgenologic observations on various types of chronic arthritis. Ann Intern Med 1936:1vii:979-98.
2.Horder T. Rheumatism; notes on its causes, its incidence and its prevention. London: H.K. Lewis; l9xx: 5-60.
3.Hench PS. Recent investigations on rheumatism and arthritis in the United States. Ann Rheum Dis 1940;ii:19-40.
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