Cartoon of gout sufferer
Whilst the field of rheumatology was first carved from internal medicine in the 20th century, rheumatic diseases have crippled humans since before recorded history, with changes of spinal arthritis described in Neanderthals, circa 50,000 BC. Other “old” joint diseases include ankylosing spondylitis and gout seen in mummies and skeletons of ancient Egypt; osteoarthritis in digs of pre-Norman England; and changes of rheumatoid arthritis and temporal arteritis in paintings by van Eyk and van Gent in the Renaissance. The French physician, Guillaume de Baillou (1538-1616) is known as the father of rheumatology* for the descriptions of rheumatism and arthritis in his textbook, Liber de Rheumatismo et Pleuritide dorsali. Englishman Thomas Sydenham (1624-1689) described the clinical features of rheumatic fever…and gout, which he suffered, as did many of the well-to-do who preceded and followed him.
*He is also known as the father of modern epidemiology, for his extensive studies of the epidemics that plagued Paris.
film of rheumatoid arthritis of hand
The 19th and 20th centuries saw rheumatology grow into a field a sui generis with the separation by Sir Alfred Garrod (1819-1907) of rheumatoid arthritis from the clinically similar, but pathogenetically distinct rheumatic fever. Garrod also described a semiquantitative test for uric acid, which was one of the seminal events in the field of laboratory medicine. In the mid-1800s, lupus erythematosus was recognized as a distinct condition, separated by Kaposi (of sarcoma fame) into discoid and systemic subtypes and described in detail by William Osler in 1895. In his 1897 doctoral thesis, George F Still (1868-1941) described a form of childhood febrile arthritis which is now cleverly known as Still’s disease.
Rheumatology was ushered into the modern era through diagnosis and treatment. The LE cell phenomenon was first recognized in the middle of the 20th century in patients with lupus. In the LE cell test, macrophages and neutrophils engulf self nuclear material a finding attributed to presence of antinuclear antibodies in lupus patients. An analogous phenomenon was identified in patients with rheumatoid arthritis, in which the so-called rheumatoid factor caused previously sensitized sheep red cells to agglutinate in the presence of serum from patients with rheumatoid arthritis. These findings led to objective diagnostic tests and an autoimmune explanation for the pathogenesis of both conditions.
Needle-shaped uric acid crystals seen by polarised light microscopy in patient with gout
Treatment of rheumatic diseases has also matured. The only effective treatment for gout known to the ancients was colchicine, derived from the autumn crocus (Colchicum autumnale), which had the downside of also acting as a purgative. Fast forward 1200 years and the rheumatology medicine cabinet had expanded to include glucocorticoids for rheumatoid arthritis (1948), allopurinol, a xanthine oxidase inhibitor used for chronic management of gout (1963), antimalarials for rheumatic diseases (1957), methotrexate for rheumatoid arthritis (1988), TNF-alpha inhibitors* and monoclonal antibodies also for rheumatoid arthritis (1999).
*Popularly known as DMARDs–disease modifying anti-rheumatic drugs.