The History of Rheumatoid Arthritis

Introduction

Rheumatoid arthritis causes inflammation of the joints and other body areas. It is an autoimmune disease and its symptoms include:

• Fever
• Joint pain in the feet, knees, and hands
• Limping
• Swollen and stiff joints
• Polyarthritis
• Tender joints
• Loss of range of motion
• Fatigue
• Anemia
• Warm joints
• Joint deformity

There are periods of arthritis flares and remissions. The joints may get permanently damaged or deformed due to chronic inflammation. Sometimes, the damage may early occur. However, the damage may not correlate with the severity of the symptoms. The antibody called rheumatoid factor (RF) is found in the blood of 80 percent of patients with rheumatoid arthritis. Rheumatoid factor (RF) can be detected by a simple blood test. The risk factors that can increase the chances of developing this disease are:

• Smoking
• Genetic background
• Periodontal disease
• Silica exposure
• Microbes in the bowels

Usually, NSAIDs, DMARDs, T cell activation inhibitors, IL-6 inhibitors, TNF-alpha inhibitors, immunosuppressants, steroids, and Janus kinase inhibitors (JAK) inhibitors are used to ease the symptoms of rheumatoid arthritis. There is no cure for the disease, but other treatment options such as joint protection, certain medications, patient education, exercise, rest, and surgery may be occasionally needed.

Better prognosis can be achieved through early detection. The exact cause of the disease is not known and it may affect people of any age. In rheumatoid arthritis, the tissues that normally produce fluid for joint lubrication become inflamed. This loosens the joint ligaments and causes deformities. It erodes away the cartilage and causes deformity. Rheumatoid arthritis is a progressive illness. Approximately 1.3 million people in the United States are affected by the disease.

History of Rheumatoid Arthritis

References to joint pain and diseases were first described around 1500 BC in the Ebers Papyrus, which is an ancient Egyptian medical papyrus. It described a disease that is quite similar to rheumatoid arthritis. Moreover, there has been evidence of rheumatoid arthritis in Egyptian mummies. In G. Elliot's studies, he found out that rheumatoid arthritis was prevalent among Egyptians.

Around 300-200 BC, an Indian literature called Charaka Samhita described a condition, which includes pain, loss of joint mobility and function, as well as joint swelling. 

In 400 BC, Hippocrates described arthritis in general. However, he did not specify the types of arthritis. Between 129 and 216 AD, the term "rheumatismus" was introduced by Galen.

In 1493-1511, it was suggested by Paracelsus that some substances collected in the body could not pass through the urine, and instead accumulate in the joints, which causes arthritis. Rheumatic diseases were often linked to humors by practitioners. Ayurveda also considered rheumatoid arthritis as one of the ata.

The disabling form of rheumatoid arthritis was first described by Thomas Sydenham. Later in 1880, such condition was described by Beauvais.

The progressive nature of rheumatoid arthritis was showed by Brodie. He also found how tendon sheaths and synovial sacs in the joints were affected. Moreover, he found other conditions associated with rheumatoid arthritis such as synovitis and cartilage damage.

First Description of RA

In the year 1800, the dissertation of Augustin Jacob Landré-Beauvais gave the first description of rheumatoid arthritis, which was also acknowledged by modern medicine. Landré-Beauvais was a 28-year-old resident physician who worked at the Saltpêtrière asylum in France. He was the first one to notice the signs and symptoms of rheumatoid arthritis. He even treated a few patients who complained of joint pain. At that time, rheumatism or osteoarthritis was still unknown. Rheumatoid arthritis affected poor people and more women than men.

At that time, physicians often treated wealthy patients to earn recognition and compensation. Hence, poor patients were ignored. Landré-Beauvais hypothesized that patients who were complaining of severe joint pain were suffering from goutte asthénique primitive or primary asthenic gout, which was an uncharacterized condition. He related gout to rheumatoid arthritis. Even though his assumption was incorrect, other researchers in the field of bone and joint disorders were encouraged to further study about the disease.

Rheumatoid Arthritis Classified

In the mid to late 19^th century, another person who studied and contributed to the study of rheumatoid arthritis was Alfred Garrod, who was an English physician. He classified rheumatoid arthritis differently from gout and he distinguished them from each other as well as from other forms of arthritis. He found that patients who had gout had an excessive uric acid in their blood. He also found out that patients with other forms of arthritis did not have increased uric acid levels in the blood.

These observations were described in Treatise on Nature of Gout and Rheumatic Gout, which was written by Alfred Garrod. He categorized and differentiated rheumatoid arthritis from gout. He referred rheumatoid arthritis as "rheumatic gout". His work and discoveries laid the groundwork for research on the etiology of rheumatoid arthritis. It was understood that the disease should have its own etiology since it was a different condition from other forms of arthritis.

How "Rheumatoid Arthritis" Was Coined

Further research was conducted by Archibald Garrod, who was the fourth son of Alfred Garrod. In his book called Treatise on Rheumatism and Rheumatoid Arthritis, he created the term "rheumatoid arthritis" to the disease that was discovered by Landré-Beauvais and later called by his father as "rheumatic gout". Archibald Garrod was known for distinguishing rheumatoid arthritis from gout and osteoarthritis.

After the discovery of the disease, it was later called by various names. However, Archibald Garrod called it as "rheumatoid arthritis" since the term would clearly describe the action of the disease on the body. In his book, he also referred to ancient skeletal remains found around the world. He claimed that the skeletal findings showed damage caused by rheumatoid arthritis. Although he was able to record such paleopathological claims, he did not include concrete supporting evidence.

Based on his claims, he said that rheumatoid arthritis is not a disease of the modern age but a disease that already existed from the time of our ancestors. Archibald Garrod's treatise acts as a supporting foundation and backbone when it comes to RA etiology.

The Antiquity of Rheumatoid Arthritis

Charles Short, an American physician, challenged the claims of Archibald Garrod during the 20^th century. Short further examined the paleontological reports and he noted that the diagnoses of ankylosing spondylitis, gout, and osteoarthritis were all confirmed in the skeletal remains. However, he found unconvincing claims of an RA diagnosis since he could not find a definitive RA diagnosis on the samples.  

Short further claimed that the ideas of Archibald Garrod were false and that rheumatoid arthritis was a disease of modern origin. Short's work was credited more even though many had valuable claims and findings regarding the basis of RA origin. 

History of RA Terms

Bannatyne described the appearance of rheumatoid arthritis that affected the joints. The International Commission on Rheumatism was formed in the year 1932. It later became the American Rheumatism Association and then the American College of Rheumatology.

The term "rheumatologist" was coined by Camroe in 1940 and "rheumatology" by Hollander in 1949.

History of RA Treatment

• Bloodletting and Leeching - These were the treatments used in the olden days for rheumatoid arthritis. Acupuncture, acupressure, cupping, and moxibustion were developed and practiced in the Far East. Although many treatments were developed, they could not improve the symptoms of rheumatoid arthritis. Heavy metals were also used to treat RA. With varying success rates, different heavy metals such as arsenic, gold, bismuth, and copper salts were used. After many years, the use of gold has shown success. Gold is still used as part of disease-modifying antirheumatic drugs, which are used in the treatment of rheumatism.

• Willow Extracts - Used by Hippocrates and Galen to treat the pain associated with rheumatoid arthritis.  By using the plant extract of willow bark and leaves, pain relief was achieved. They also used the same extract to treat other forms of arthritis. 

• Salicylic Acid - In 1929, salicylic acid was identified as an active substance that could ease the pain. The substance was identified by Henri Leroux, a French chemist.

• Acetylsalicylic Acid - Gerhardt synthesized acetylsalicylic acid in the year 1853. Then in the year 1949, phenylbutazone and many other nonsteroidal anti-inflammatory agents came into existence.

• Disease-Modifying Antirheumatic Drugs (DMARDs) - The first one to suggest the use of quinine to treat rheumatic diseases was Payne in 1895.

• Chloroquine - It was used in the year 1957. A modified version called hydroxychloroquine is used as a part of DMARDs until now.

• Sulphasalazine - It was used as an anti-inflammatory agent in 1940 until today.

• Cortisone - The successful use of cortisone in treating rheumatoid arthritis was first showed by Edward Kendall and Philip Hench in the year 1949.

• Methotrexate - Methotrexate was synthesized in the 1950s. It was used as a folate antagonist for the treatment of leukemia. However, its role in treating rheumatoid arthritis was not discovered until the 1980s. Methotrexate still forms a part of DMARDs.

• Anti-TNF Antibodies - The role of monocyte-derived tumor necrosis factor in the pathogenesis of rheumatoid arthritis was first identified in 1975. Their effectiveness was shown in the year 1993 and became a part of rheumatoid arthritis treatment.

Literature and Art Evidence on Rheumatoid Arthritis

Some researchers suggest that rheumatoid arthritis has been described in ancient texts even though the first accepted medical report regarding RA was the dissertation of Landré-Beauvais.

Hippocrates, in one text, described a patient with symptoms quite similar to rheumatoid arthritis. In the writings of Arataeus, a Greek physician, a similar description could be found.

Similar descriptions were also found in the writings of:

• Scribonius - Caesar's physician 

• Michael Psellus - Emperor Constantine IX's adviser 

• Soranus - A Byzantine physician 

The ones who believe that rheumatoid arthritis is a disease of the ancient times and are in favor of the Ancient Origin view of etiology of rheumatoid arthritis. They use these texts as an evidence since the symptoms described in the writings were very close to those of rheumatoid arthritis.

However, some argue that the descriptions in these texts are vague and do not meet the scientific standards. Moreover, they provide insufficient evidence for the existence of the disease. Thus, the ancient literature's role in etiology still remains anecdotal.

However, the demonstration of rheumatoid arthritis has been successfully displayed by much artwork. One painting is The Three Graces done by Peter Paul Rubens. Such artwork remains to be one of the most pronounced artistic pieces of RA evidence. It was done even before the thesis of Landré-Beauvais.

Another pronounced case was made by an anonymous painter's depiction of The Temptation of St. Anthony. This painting was reported by Dequeker and Rico in 1992. The painting was made during the mid 15^th to late 16^th centuries. In the painting, the beggar's right hand showed ulnar deviations, wrist dislocation, and finger contractures, which closely resemble the hand condition of a patient with rheumatoid arthritis.

However, any conclusion drawn from paintings should be carefully considered since artwork are not usually regarded as scientific evidence.