History and Geography

The clinical term “rheumatoid arthritis” was first introduced in the medical literature by A. B. Garrod in 1859. It was not in common usage until “officially recognized” in the United Kingdom by the Depart­ment ofHealth in 1922 and by the American Rheuma­tism Association in 1941.

Evidence for the existence of rheumatoid arthritis in earlier times, however, must be gleaned from lit­erature, from art, and from paleopathological stud­ies of ancient bones, and to date that evidence has been far from overwhelming. Indeed the lack of early descriptions of this disease led authors such as E. Snorrason (1952) to suggest that the disease is recent in origin (i.e., since the seventeenth century) and is evolving to develop a peak incidence during the twentieth century before ultimately disappear­ing (Buchanan and Murdoch 1979).

By contrast, other arthritic disorders such as ankylosing spondylitis, osteoarthritis, and spinal hyperostosis have been recognized in skeletons thou­sands of years old and appear to be unchanged from the present condition. In fact, given the lack of evi­dence of the existence of rheumatoid arthritis until relatively recent times, L. Klepinger (1979) and oth­ers have suggested that rheumatoid arthritis has evolved from ankylosing spondylitis. Suffice it to say that the uncertainty about the antiquity of rheuma­toid arthritis is at least partly due to the methods by which we have examined the evidence of a disease whose current definition includes a combination of clinical, radiological, and serologic criteria.

Literature

In 1800, A. J. Landre-Beauvais wrote an account of a disease that is today universally accepted as rep­resenting rheumatoid arthritis. Earlier European descriptions of rheumatoid arthritis, which C. L. Short (1974) and the present authors find convinc­ing, were written by Thomas Sydenham in 1676, W. Heberden in 1770, and B. Brodie in 1818. These observers each described long-term, chronic, debili­tating diseases affecting multiple joints, which in­cluded descriptions of typical hyperextension defor­mity of the Interphalangeal joints of the fingers. Before these dates, there are several descriptions of disease that could represent certain phases of rheu­matoid arthritis, ranging from the acute explosive attack to one of chronic sustained disability. This is particularly so in the case of the Emperor Constan­tine IX (ca. 980-1055) who, at the age of 63, suf­fered from polyarthritis in the feet, and subse­quently the hands, shoulders, and knees, leading to a nodularity and residual deformity in the fingers, and flexion and swelling of the knees. However, the absence of currently applied diagnostic criteria based on skeletal X-rays and serologic information does not absolutely exclude a diagnosis of polyartic­ular gout or some other erosive joint disease in an otherwise very suggestive report.

In the thirteenth century, a less complete descrip­tion was written in Britain by Bartolemeus Anglicus who, after describing several types of arthritis, stated that “one form of the disease is worse for it draws together tissues and makes the fingers shrink and shrivels the toes and sinews of the feet and of the hands.”

Perhaps the earliest known description suggestive of rheumatoid arthritis is in the Eastern literature (India) and discussed in the Cαrαkα Samhita, writ­ten about A.D. 123. In this work, the disease in question was said to manifest itself as swollen, pain­ful joints initially in the hands and feet and then affecting the whole body. The ailment was reported to be protracted, difficult to cure, and associated with anorexia.

Art

Although there is no unequivocal illustration of sym­metrical polyarthritis, attention has been drawn to some presentations of deformities of the hands in the Flemish painters (1400-1700) who otherwise painted the ideal, unaffected limb with considerable accuracy (Klepinger 1979). Some works of Peter Paul Rubens show changes typical of rheumatoid arthritis, suggesting to T. Appelbloom and col­leagues (1981) that Rubens, who himself suffered from rheumatoid arthritis, painted the progressive phases of his own disease in the hands of his sub­jects during the years 1609-38.

Paleopathology

Of the thousands of mummies and whole skeletons from the distant past that have been observed, there are surprisingly few specimens that show features compatible with rheumatoid arthritis. The reader will recall that the definition of the disease requires a symmetrical pattern commonly affecting the small joints. This poses a problem when the determination of symmetry is not possible because one or more long bones are absent or because the small bones of the hands and feet are frequently lost.

Although rheumatoid arthritis, at the present time, is a major cause of symmetrical erosive polyarthritis, other causes do exist, and thus it seems appropriate to employ the term “erosive joint disease,” which may or may not have been rheuma­toid arthritis when describing the arthritis seen in ancient bones.

The description by W. P May (1897) of an Egyp­tian mummy 5,500 years old indicates a case of possible rheumatoid arthritis: a male, 50 or 60 years of age with hands, wrists, elbows, and knees, and feet affected. Particular note was made of the fingers — “small joints of the hands are swollen and fusiform” - while the metatarsophalangeal joints were markedly involved with some peripheral fu­sion. The author emphasized the unequal symme­try, and no erosions were described.

A detailed analysis of a well-preserved 34-year-old female Eskimo mummy from the Kodiak Islands is described by D. Ortner and C. S. Utermohle (1981); in this instance evidence of erosive inflammatory polyarthritis compatible with juvenile rheumatoid arthritis is clearly presented. More recently, reports of erosive polyarthritis occurring in ancient bones ranging from 5,000 years to 1,000 years old in North America have been identified by B. M. Rothschild’s group (1987). In fact, Rothschild and colleagues have speculated that rheumatoid arthritis could have had a viral origin in North America and then migrated to Europe in the post-Columbian period, where it manifested itself as a more severe disease in subse­quent centuries. This, they argue, might account for the apparent relative infrequency of the disease in Europe prior to the seventeenth century.

Today the disease is identified in most ethnic groups and in all parts of the world. Thus only de­tailed studies and precise reports on skeletal re­mains can establish whether erosive arthritis, which may have been rheumatoid arthritis, was more prevalent in the past than it is presently. These findings could impact considerably upon our under­standing of the pathogenesis of the disease and per­haps also suggest whether it is likely to disappear as some have argued.

Howard Duncan and James C. C. Leisen