Rheumatism in Sweden.

HISTORICAL A survey of rheumatic diseases was made by the Swedish Government at the beginning of this century, and the situation was found, as had been expected, to be that this group of diseases was involving the country in great expense, and that treatment facilities were non-existent for a large proportion of cases. In Sweden the large majority of workers are insured, and become eligible for pension based upon their previous income if they become incapacitated; rheumatic cripples thus become pensionable. In 1915 the National Pensions Board completed an arrangement whereby a variable number of beds was reserved for these cases in general hospitals if they were unable to continue with their employment. Their fees were paid by the Board for a period up to two months. In 1918 Kahlmeter, who was C.M.O. for the Pensions Board, conducted a further survey and found that in that year there were more than 50,000 patients pensionable from this group of diseases, whilst 5,000 new cases came into this category during the year. As a result of this the Board in 1920 bought two spas, Nyniishamn and Tranas, and built special rheumatic hospitals in these, each capable of accommodating 200 patients. A third was added in 1923 (Are). Cases were allocated to these from the central office in Stockholm. In 1926-1927 the policy changed, and it was considered desirable that these patients should be accommodated and treated in special centres situated in the five chief regional general hospitals of the country. The advantages were considered to be: (a) full facilities for ancillary services and special opinions; (b) increased interest in academic medical circles; (c) facilities to train physicians for diagnosis, treatment, and research in this field. By the end of 1927, 345 beds had been established in this way. The largest unit was at Lund (120 beds). In each case they came under the general direction of the Professor of Medicine; a physician of the rank of Docent (Reader, lecturer), with a special interest in the subject, being appointed in charge; a consulting orthopaedic surgeon, being specially attached and having beds in the same block. Two years later another such department was added in the Norrkoping region. This system worked well from the administration point of view, but conflict developed between the professors of medicine, where these were not particularly interested in the subject, and the Docent in charge, the former taking the view that rheumatism is only a minor field of general medicine and that specialized consideration would give exaggerated importance (Svartz); the Docents' view being that, with the specialized facilities and interest at their disposal, great advances could be made if the repressive academic influence could be removed, and the subject become a free speciality with the status of a special department (Edstrom). Some wished to revert to the special hospital system, with the addition of visiting specialists (Sunderlin) from regional centres.