|Year : 2014 | Volume
| Issue : 2 | Page : 119-123
History of rheumatology
Department of Ophthalmology, MGM Medical College, Navi Mumbai, Maharashtra, India
|Date of Web Publication||4-Feb-2014|
Department of Ophthalmology, MGM Medical College, Kamothe, Navi Mumbai - 410 206, Maharashtra
Source of Support: None, Conflict of Interest: None
This article describes the history and various milestones of rheumatology from ancient to modern times. The origin of rheumatology can be traced to ancient times. Diseases such as gout and osteoarthritis were prevalent in ancient people. Many ancient skeletons show signs of gout and osteoarthritis. The ancient book on Indian Medicine, Charaka Samhita, gives a vivid description of many variants of arthritis. Charaka, an eminent Ayurvedic physician, described rheumatoid arthritis (RA) in Charaka Samhitha as "Vishkantha," meaning painful joints. The word rheumatology has its origin in the word "rheuma," which means flowing, and is mentioned in Hippocratic corpus. Hippocrates made several observations about gout, popularly known as "aphorisms of gout." Many famous paintings in the medieval era depict joint diseases. Hand lesions resembling those of RA are found in paintings of the Flemish school. "The virgin with canon van der paele," a painting by Jan Van Eyck (1436), shows thickened arteries in the temple, suggestive of temporal arthritis. The famous portrait of Federigo de Montefeltre, thought to have been painted by Joos (Justus) van Gent, shows arthritis of the proximal interphalangeal joint of the left index finger. Rheumatology developed as a well-recognized specialty of medicine in the 20th century. American Physicians Bernard Comroe and Joseph Lee Hollander coined the term rheumatologist in 1940. Rheumatology has rapidly advanced during the last 50 years due to improved diagnosis as a result of progress in immunology, molecular biology, genetics and imaging.
Keywords: Gout, rheumatology, rheumatoid arthritis
|How to cite this article:|
Deshpande S. History of rheumatology. Med J DY Patil Univ 2014;7:119-23
| Introduction|| |
The origin of rheumatology can be traced to ancient times. Diseases such as gout and osteoarthritis were prevalent in ancient people. Many ancient skeletons show signs of gout and osteoarthritis. Examination of 400 Saxon, Romano-British and mediaeval skeletons from seven archaeological excavations in the west of England showed changes suggestive of arthritis, osteoarthritis and osteophytosis.  Changes suggestive of ankylosing spondylitis were found in the 3000-year-old Egyptian mummy of Rames II. Two skeletons of ancient Egyptians dated to about 1500 BC show radiological signs suggestive of ankylosing spondylosis.  Egyptians first identified gout, known as podagra, in 2640 BC.
Many historical persons suffered from rheumatic diseases [Table 1].
The ancient book on Indian Medicine, Charaka Samhita, gives a vivid description of many variants of arthritis. Charaka, an eminent Ayurvedic physician, described rheumatoid arthritis (RA) in Charaka Samhitha as "Vishkantha," meaning painful joints. 
The word rheumatology has its origin in the word "rheuma," which means flowing, and is mentioned in Hippocratic corpus.
Hippocrates made several observations about gout, popularly known as "aphorisms of gout." He said, "Eunuchs do not take gout, nor become bald. A woman does not take gout unless her menses is stopped. A young man does not take gout unless he indulges in coitus. In gouty affection, inflammation subsides in 40 days." Hippocrates termed gout as "the unwalkable disease." Hippocrates observed that podagra was related to affluent lifestyle and termed it as "arthritis of the rich." 
Galen described tophi, the crystallized monosodium urate deposits present in gout. He listed debauchery, intemperance and hereditary as etiological factors associated with gout. 
The Greek physician Soranus of Ephesus in the second century AD described the differences between gout and other types of arthritis in his treatise on acute and chronic diseases. 
The Dominican monk, Randolphus of Bocking (1197-1258), was the first person to use the term gout. The term gout is derived from the Latin word gutta (or drop), and referred to the prevailing medieval belief that gout results from an excess of one of the four "humors" that "drop" or flow into a joint, causing pain and inflammation. 
Many famous paintings in the medieval era depict joint diseases. Hand lesions resembling those of RA are found in paintings of the Flemish school. "The virgin with canon van der paele," a painting by Jan Van Eyck (1436), shows thickened arteries in the temple, suggestive of temporal arthritis. The famous portrait of Federigo de Montefeltre, thought to have been painted by Joos (Justus) van Gent, shows arthritis of the proximal interphalangeal joint of the left index finger. 
Guillaume de Baillou (1538-1616), a French physician, introduced the term "rheumatism" for joint ailments in his book titled "The Book on Rheumatism and Back pain." He is known as the father of rheumatology. He tried to distinguish gout from other rheumatic disorders. 
Thomas Sydenham (1624-1689), known famously as "The English Hippocrates," described the clinical features of rheumatic fever. He called it as "acute febrile polyarthritis." He made the following observations about gout, "The patient goes to bed and sleeps quietly until about two in the morning when he is awakened by a pain which usually seizes the great toe, but sometimes the heel, the calf of the leg or the ankle. The pain resembles that of a dislocated bone and this is immediately succeeded by a chillness, shivering and a slight fever, pain, which is mild in the beginning, grows gradually more violent every hour, so exquisitely painful as not to endure the weight of the clothes nor the shaking of the room from a person walking briskly therein." Ironically, he himself was suffering from gout and renal disease. Thomas Sydenham wrote a classical description of chorea. 
William Heberden (1710-1801) described nodular swellings in osteoarthritis, subsequently known as Heberden's nodes. He described the differences between gout and osteoarthritis. 
Sir Alfred Garrod introduced the term RA as a specific chronic joint disease different from gout and rheumatic fever in his book, Gout and Rheumatic gout (1859). Sir Alfred Baring Garrod described a semiquantitative method for the measurement of uric acid in the serum or urine known as "thread test." It was the first clinical chemical test ever undertaken. 
Sir George F Still described a clinical variant of RA, named after him in 1897.  AR Felty in 1924 described features of a variant, now known as Felty's syndrome. 
Biett and Cazenave described lupus as erythema centrifugum in 1833. In 1851, Cazenave renamed it as Lupus Erythematosus. Kaposi divided lupus into discoid and systemic forms in 1872. Sir William Osler described systemic manifestations of lupus in 1895. 
Progress of Rheumatology in the 20 th Century
Rheumatology developed as a well-recognized specialty of medicine in the 20 th century.
American Physicians, Bernard Comroe and Joseph Lee Hollander, coined the term rheumatologist in 1940. 
1948, a landmark year
1948 was a landmark year in rheumatology as three important discoveries were made in the same year. Hargraves and colleagues discovered the LE cell phenomenon in 1948. They observed nuclear alterations with phagocytosis of the remnants of the nucleus when leucocytes were incubated with the serum of patients with systemic lupus erythematosus (SLE). They demonstrated that the LE cell phenomenon was related to a serum factor present in patients with SLE that reacted with the nuclear material. This factor was subsequently named as antinuclear factor.  Harry M Rose and Erik Waaler discovered RA factor by observing agglutination of sensitized sheep erythrocytes by sera of patients with RA.  This led to the development of a serological test for the diagnosis of RA. Phillip Hench and his colleagues introduced corticosteroids for the treatment of RA in the same year. 
Demonstration of the presence of antibodies directed against self-antigens such as lupus anticoagulant (Conley in 1952) and antinuclear antibodies (Frou in 1958) changed the thinking about the possible etiology of rheumatic diseases from infective to auto-immune in the 1950s. 
HLA B 27
Schlosstein and colleagues reported a significant association between HLA B27 antigen and ankylosing spondylitis in 1970. This was a significant development in understanding the etiology of rheumatic diseases. 
Rheumatology has rapidly advanced during the last 50 years due to improved diagnosis as a result of progress in immunology, molecular biology, genetics and imaging. Disease-specific criteria have been developed for majority of rheumatic diseases during the last 50 years to keep uniformity in diagnosis and classification. Various assessment scales and indices such as the Health Assessment Questionnaire (HAQ), DAS-28 (for RA) and SLEDAI (SLE) have been developed in the last 25 years. These help clinicians to objectively assess the severity and response to treatment and help clinicians to modify the treatment. The HAQ, published in 1980, was among the first instruments based on generic, patient-centered dimensions to assess the severity of RA. It was originally developed in 1978 by James F Fries, MD, and colleagues at Stanford University. HAQ has established itself as a valuable, effective and sensitive tool for the measurement of health status over two decades of its continuous use. 
The American College of Rheumatology has developed the ACR success criteria, referred commonly as ACR 20/50/70, to assess improvements in outcomes such as pain, disease activity and physical activity as assessed by patients, the physician's global assessment of disease activity and acute phase reactant in RA. The 20, 50 or 70 designations refer to improvements in percentage terms to 20%, 50% or 70% in the relevant dimensions. The ACR criteria have immensely helped in shifting the entire focus to patient-related outcomes. 
Advances in molecular biology have helped in better understanding of the disease process as well as finding new therapeutic targets such as inflammatory mediators.
Evolution of Treatment of Rheumatologic Diseases from Ancient to Modern Times
Various therapies were used for rheumatic ailments in ancient times. Diet therapy for gout is in vogue since Hippocrates. Hippocrates, Sydenham and Galen advocated barley water and barley bread for gout. Antonius Musa in AD 10 successfully used diet therapy for the treatment of rheumatism of Emperor Augustus. AB Garrod suggested that hyperuricemia could be controlled by lowering the intake of purine-rich food. Haig confirmed this by conducting experiments on himself from 1894 to 1897. 
Hippocrates also advised purgative therapy for the treatment of gout. He used purgatives for intractable cases of chronic gout.
Various forms of spa therapy such as hot water bath and cold water therapy were used since ancient times for the treatment of rheumatologic diseases. Other therapies tried for arthritis were blood letting and counter irritants.
Byzantine Christian physician Alexander of Tralles successfully used colchicine, an alkaloid derived from the autumn crocus (Colchicum autumnale), for the treatment of gout in the sixth century. The gastrointestinal adverse effects of colchicine were recognized in ancient times. The use of colchicine for gout became sparse due to its purgative properties. Sydenham discouraged all forms of purgative therapy as he regarded all purgatives as toxic. Colchicine was re-discovered in 1763 by Professor Baron Von Stoerk in Vienna. 
The use of uricosuric agents for the treatment of gout started in the last quarter of the 19 th century.
Ancient Egyptians and Assyrians used willow extract to reduce the redness and pain of inflamed joints. The use of anti-inflammatory agents in modern times started in the 16th century. Edward Stone successfully used willow bark for fever in 50 patients based on the doctrine of signatures.  Johann Andreas Buchner prepared salicin, a partially purified extract of willow bark, in 1828. Hammond Kolbe synthesized salicylic acid in 1859. 
Felix Hoffman in 1897 synthesized pure stable acetyl salicylic acid, commonly known as aspirin, from Acetyl Spirea as he found salicylic acid to be bitter and irritating to the mouth.  Aspirin since then is used extensively for the treatment of RA and rheumatic fever.
Treatment Milestones of Rheumatology in Modern Times
Treatment of RA with glucocorticoids
Philip Showalter Hench, a rheumatologist in the US Armed Forces, successfully treated a patient of RA with glucocorticoids in 1948. This was a major milestone in rheumatology. Hench observed that pregnancy and jaundice ameliorate RA. He attributed this to raised corticosteroid levels in these conditions, which prompted him to try glucocorticoids in RA.  He was awarded the Nobel Prize for his work on glucocorticoids.
Allopurinol was the first xanthine oxidase inhibitor to be used in the treatment of gout in 1963.  George Hitchings and Gertrude Elion were awarded the 1988 Nobel Prize in medicine for their work in developing allopurinol, azathioprine and five other drugs.
Another milestone for rheumatology came in 1968 when Malaviya and colleagues used methotrexate for the treatment of dermatomyositis.  Methotrexate, a chemical analogue of folic acid, was developed by Yellapragada Subbarao, an Indian scientist working in the US. Low-dose methotrexate became a pivotal drug for the treatment of many rheumatologic diseases owing to its efficacy and low toxicity. It was approved for the treatment of RA by the US Food and Drug Agency in 1988. 
Vane and colleagues determined the mechanism of action of aspirin in the 1970s when they showed that aspirin blocked the synthesis of prostaglandin E. This paved the way for the development of other anti-inflammatory agents. 
Page first used the anti-malarial drug, quinacrine, for the treatment of lupus in 1951.  Chloroquine was used by Bagnall in 1957 for the treatment of rheumatic diseases.  Hydroxychloroquine is widely used today for the treatment of many rheumatic diseases due to its efficacy and better safety profile. 
Introduction of biological agents
Introduction of biological disease-modifying agents such as infliximab was a landmark development in treatment of rheumatic diseases. Sir Ravinder Maini and Marc Feldmann in their pioneering research work reported the presence of high quantities of tumor necrosis factor (TNF) in the blood and tissues of patients with RA. They demonstrated that the TNF-blocker had a powerful effect in animal models of RA in 1992. In 1993, Maini tested TNF-blockers for the first time and reported wonderful results.  These drugs were introduced in the market in 1999.
The Community-Oriented Program for Control of Rheumatic Diseases (COPCORD) program was launched by the World Health Organization (WHO) and International League of Associations for Rheumatology in the 1980s. The main aim of the COPCORD program was to measure and evaluate "pain and disability" in rheumatic disorders by conducting population surveys. It also aimed to impart health education about rheumatic disorders and to control the risk factors, especially in developing countries. The COPCORD program has been successful in highlighting the burden of rheumatic diseases and has helped in the development of rheumatology, especially in developing countries like India. 
The Bone and Joint Decade (BJD), an independent global non-profit organization launched in 2000 and endorsed by the WHO, has helped immensely to improve the public awareness, diagnosis and treatment of rheumatic diseases. The priorities of BJD India are to create awareness about rheumatic musculoskeletal disorders among doctors and the general public. It has also set up several studies to collect population-based prevalence data. 
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