TJ Hodgetts. Reiter's disease: an historical review of a soldiers' disease


1 R A rmy Med Corps 1990 : 136: 170-1 72 

Reiter's disease: an historical review of a soldiers' disease 

Capt T J Hodgetts 
MB, BS, Dip IMC RCSIEd). RAMC 
Senior House Officer in Medicine 
Briti,~1t Military Hmpiral HannoJ)cr, Brili,I,1t Force~' ['osr Office 33 

A Espinosa 
MD 
Assistant 
Insrirut fijr Medizinische In!ormatik , Medi z inische Hochschule Hannover 

SUMMARY: Major conflicts in history have yielded an equal number of medical casualties as those injured in battle, and 
no more common a problem exists in the insanitary conditions of war as dysentery. The complication of arthritis following 
dysentery has been documented since ancient times, but it is not until the 16th Ctmtury that these cases appear in an)' 
numbers, and then it is predominantly in military personnel. "'Reiter's Disease" is currently understood to mean an 
asymmetrical, predominantly lower-limb pol)'arthritis developing after urethritis (usually non-gonococcal) or d}'sentery; 
conjunctivitis is not always a constant feature. This is the commonest inflammatory polyarthropathy of young men and 
both the epidemic (dysenteric) and sporadic (venereal) forms arc historically prel'alent in soldiers - a not surprising fact 
considering the squalor of war and the unrestrained behaviour of the Private soldier. This paper traces the history of 
Reiter's disease and highlights its affinity for military populations. 

Introduction 
In 1916 Hans Conrad R~iter was 25 and serving with 

the First Hungarian Army on the Balkan front, On 14th 
October he was presented at the reserve hospital with a 
young Prussian Cavalry Lieutenant who had developed 
urethritis, arthritis ami conjunctivitis following a bout of 
bloody diarrhoea. This single case was published(l) , and 
despite his wrongly attributing it to a spirochaete - he 
called it "Spirochaetosis arthritica" (perhaps flushed 
with success from isolating the causative organism of 
Weil's disease in 1914)(2) - this collection of symptoms 
has come to be known as "Reiter's Disease". 

At the same time Fiessinger and Leroy reported four 
cases of urethritis , conjunctivitis and arthritis of the 
peripheral and spinal joints following an outbreak of 
bacillary dysentery in French troops on the Somrne(3,4). 
Cases were drawn from all Arms and Corps, including 
thirty regiments of infantry , along a twenty five 
kilometre frunt, To the French this is still the 
"Fiessinger-Leroy syndrome", 

History 
Arthritis is however as old as man - a fact borne out 

by paleopathological evide nce of destructive joint 
disease(5) , but the first written association of urethritis 
and arthritis may be attributed to the FatherofMedicine 
and ancient chronicler, Hippocrates of Cos (460-377 
BC); within the " Corpus Hippocraticum " he notes that 
young men do not develop gout until they are sexually 
active , perhaps identifying an association between a 
sexually transmissible agent and arthritis(6). 

Some six centuries later, Caelius Aurelianus (noted 
for hi s description of coronary thrombosis and for his 
translation of the works of probably the first psychiatrist , 

Hans Conrad Reiler (1881 -1 969) 
Taken from "Das Reichsgesundheitsamt /933- 39 " 

Courtesy Springe r Verlag 

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T J Hodgetts 

Soranus of Ephesus )(7,8), detailed a case of arthritis 
following dysentery which he termed "Rheumatismus 
intestinalis cum' ulcere"(9), although like the records of 
other ancient writers this was an isolated account. 

A further sporadic case can be found in "De incerto, 
fallaci urinarum judicio" - observations on a collection 
of patients with genitourinary disease by Pieter van 
Foreest (alias Petrus Forestus). A university professor 
and dubbed "The Dutch Hippocrates", he described a 
patient with knee arthritis and urethritis in 1575. 

The first collection of documented "Reiter's" 
sufferers appears in a military context in 1664 in the 
published notes of Pierre Martiniere, Campaign Doctor 

, to Friedrich Ill, who noted the association of urethritis 
and arthritis while researching the "maladie 
venerienne" on an expedition to Denmark(lO). 

The Genoese explorer, Christopher Columbus (1451-
1505), has been blamed by medical historians for 
importing syphilis into the Old World, although this fact 
is certainly disputed. It has been suggested that part of 
his lengthy illness during the second voyage to the 
Caribbean (1493-96) could be a result of a reactive 
arthritis(11,12) - he had both arthritis and painful, red 
eyes. This is interesting when it is considered that the 
first apparent Northern European cases occur after 
Columbus' time: it is tempting to suggest that if the 
spirochaete could have been imported, then so could an 
agent responsible for Reiter's disease. 

By the middle of the 17th Century, dysentery 
appeared regularly in medical writings and along with it 
the recognised complication of arthritis - this is 
particularly true of Sydenham, Morton and Willis' 
description of the great dysentery epidemic of 1668-72. 
Military writers accurately describe outbreaks of 
dysentery in the Army(13) and the English fleet off 
Minorca(14), but not all authors recognised a 
connection with arthritis, urethritis or conjunctivitis. 

There is considerable information from the naval and 
army surgeons stationed in the Caribbean who studied 
and treated outbreaks of dysentery among negro slaves, 
the British garrison and the fleet. In the aftermath of a 
great hurricane that swept through the Jamaican fleet in 
1804, James Trotter made frequent references to 
"dysuria dysenterica" in the ensuing dysentery 
epidemic(15). 

A few years later in England in 1818, Sir Benjamin 
• Collins Brodie (an Assistant Surgeon at St. George's 

Hospital) became aware of a disease" ... which as far as 
I know has not been described by any pathological or 
surgical writer". This was certainly the clearest, if not 
the first, description to date of the triad later ascribed to 
Reiter; he detailed five cases of recurrent large joint 

- arthritis(16) associated with urethritis and 
conjunctivitis, and included in his account a soldier in 
the Regiment of Life Guards forced to leave the Army 
as a result of a relapsing arthritis in his right knee. 

Dysentery has always been an adjunct and sequel to 
war. The war-pestilence of Athens during the 

171 

Peloponnesian War is mirrored in records of major 
conflicts from the 17th Century. The Crimean War 
(1854-56) is notorious for the appalling hardships 
endured by the troops and dysentery was rife, ranking 
with typhus and typhoid as major causes of mortality; it 
has been estimated that 9,500 were invalided from this 
war and 1,200 were due to "rheumatic disorders"(17). It 
is likely that a large proportion of these were secondary 
to a reactive arthritis, as this is undoubtedly one of the 
commonest inflammatory arthropathies of young men. 

Figures for admissions to the Regimental Hospitals in 
the Peninsula War forty years before also show a strong 
correlation between the incidence of dysentery (23,200 
cases between December 1811 and June 1814) and 
rheumatism (4,900 cases over the same period). 

Little attention appears to have been paid to this 
relatively common sequel to dysentery in the soldier 
until Phi lip Manson-Bahr in 1920 collated reports from 
troops in India, Fiji and during the Egyptian and 
Palestine campaigns(18). Estimates of the incidence of 
reactive arthritis in these military populations ranged 
from 0 to 10%. He is quoted as saying ". . . it was 
bacillary dysentery and not the Turk that drove us out of 
Gallipoli", but unfortunately this is not corroborated 
with numbers of complications. 

Contemporary Evolution 
Hans Reiter continued his interest in the syndrome 

and retracted the spirochaetal theory a year later; 
through his influential appointments in the Nazi 
government (as President of the Health Department in 
Berlin and Professor of Hygiene at the University) he 
worked to apply better hygiene in the field(19). 

With the Second World War came renewed reports of 
Reiter's disease in epidemic proportions, closely related 
to outbreaks of dysentery. The first of these was in field 
troops in Poland in 1940(20). Later, across the Russian 
front with Finland in 1944, 344 cases were evacuated 
through the 56th War Hospital in Nokia(21). Some of 
these were mild and returned to their units fit for duty, 
others required prolonged rehabilitation and remained 
confined to a hospital for disabled servicemen until after 
the War. Ilmar Paranen agreed that "Most cases [of 
Reiter's disease] have appeared in wartime, when 
conditions have been particularly favourable for the 
spread of dysentery, but the opportunities for scientific 
study are also more limited than in times of peace" . 

More recently, nine cases developed after a Shigella 
epidemic aboard an American Naval vessel in June 1962 
- this followed an anniversary picnic meal prepared by 
the ship's cooks, two of whom had contracted dysentery 
ashore(22). 

Epilogue 
It is clear that in war Reiter's disease may reach 

epidemic proportions in circumstances of overcrowding 
and squalor, where dysentery can readily spread. 
Although venereal disease is also common in war (in 

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172 

1944,4,000 British servicemen were treated for venereal 
disease in one month(23» it probably causes less 
wastage in men through reactive arthritis than does 
dysentery; it is the main cause, however, of sporadic 
cases of Reiter's disease in the peace-time soldier and 
this has been confirmed by Dutch and French 
studies(24,25). 

The early authors were astute enough to recognise the 
association between dysentery and arthritis, but there 
were no doubt many other swollen knees and painful 
heels on the battlefield, in whom previous dysentery or 
concomitant (and perhaps asymptomatic) urethritis had 
not been considered to be causal. It may be argued that 
some of these reports could equally represent a 
gonococcal arthritis or even inflammatory bowel disease 
associated arthritis; they should be judged in the light of 
the recognised Reiter's epidemics since the Great War. 

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