The ACR/ARHP Annual Meeting Provides Look Back at History of Rheumatology

There was a great challenge in defining the “rheumatic diseases.” The original definitions implied that they were related to the internal flow of abnormal humors, such as phlegm or black bile. Nowadays, when using the term, we often employ a circular argument, namely, “we know a rheumatic disease when we see one.” This may also be the case with other well-known monikers employed in our lexicon, such as collagen vascular disorder, connective tissue disease, and systemic lupus erythematosus. It seems that for the past 150 years, rheumatic diseases were often identified by using charming descriptors. Talk about wolves with red cheeks! Sometimes, the less than charming adjective “senile” was applied to a host of musculoskeletal ailments to emphasize their association with the aging process.

Neurologists took a different approach to naming diseases. They named many of their diseases after the person who was believed to have first described the condition. It seems that when rheumatology followed this path, more problems were created. While preparing an article about the history of vasculitis, Eric Matteson, MD, professor of medicine at the Mayo Clinic in Rochester, Minn., uncovered the truth about Friedrich Wegener’s Nazi past. And although he was convicted of war crimes, Hans Reiter’s name was used until recently to describe the well-known triad of arthritis, conjunctivitis, and urethritis. So much for honoring individuals.

Two Hundred Years of Confusion?

A timeline describing the scientific understanding of rheumatology might include four distinct eras. The first would be the Rheumatism Age, when every “rheumatic” affliction was attributed to rheumatic fever. Poor public hygiene allowed for the widespread dissemination of this infectious illness. The fact that a major manifestation of rheumatic fever is acute arthritis resulted in clinicians always considering rheumatic fever when evaluating any patient with joint pain.

The next phase of the timeline was the Description Era, when astute clinicians began to classify certain conditions as being unique diseases, unrelated to rheumatic fever. Though the names of the diseases demonstrated little understanding of the conditions, they allowed certain illnesses to begin to move away from the designation of rheumatic fever.

For example, there is lupus “the wolf,” polymyalgia rheumatica, and rheumatoid arthritis (RA). However, the latter two names seem to be efforts by the authors to hedge their bets. After all, isn’t the word “rheumatoid” simply an adjective for rheumatism? Following this period came the Enlightenment Era, when classification of rheumatologic diseases became more firmly established and therapy options moved beyond salicylates and the sparkling waters of the spa. This was a time when gold salt therapy emerged as a key treatment for RA and the development of corticosteroids was just over the horizon.

Two Hundred Years Of?

To commemorate its two hundredth year of publication, the New England Journal of Medicine (NEJM) recently posted a timeline and a documentary video of what their editors selected as the major breakthrough papers that have been published during this time (http://nejm200.nejm.org). Rheumatology fares poorly. There is just a single entry; “On stiff and painful shoulders: The anatomy of the subdeltoid or subacromial bursa and its clinical importance,” written by the noted orthopedic surgeon, E.A. Codman, MD, of the Massachusetts General Hospital (MGH) in Boston. This was considered to be the seminal paper published in NEJM in over two centuries!