Rheumatoid arthritis: an example of ecological succession?

The history of one of the most common of modern-day diseases, rheumatoid arthritis, is reviewed. The disease probably existed prior to 1800 when it was first clearly described, but appears to have become much more common after this time. During the past two decades both the incidence and severity may have been declining. Vasculitis appears today certainly to be less common. The reason for this decline is considered in comparison with the decline in other infectious and non-infectious diseases. A hypothesis is put forward to explain the decline in terms of the botanical concept of ecological succession. Resume. L'histoire de l'une des maladies les plus Communes chez l'homme, l'arthrite rhumatismale, est exposee dans le present article. La maladie a probablement exist6 avant 1800, date B laquelle eile a 6th decrite pour la premiere fois, mais elle semble &re devenue beaucoup plus commune B partir de cette epoque. Au cours des deux dernieres dkcennies, l'incidence et la gravite de la maladie ont peut4tre decline. La vascularit6 est certainement aujourd'hui moins commune. La raison de ce declin est examinee en faisant une comparaison avec le declin d'autres maladies infectieuses et noninfectieuses. Une hypothese est mise en avant pour expliquer ce declin dans les termes du concept botanique de succession ecologique. We believe that there is a case for studying disease over a span of time. In the present discussion we adopt this approach with respect to rheumatoid arthritis, one of the most enigmatic of modern-day illnesses. In so doing, we attempt to show that the disease was relatively rare before 1800, and that its severity has begun to decline. An infectious cause is most likely, and the behavior consistent with ecological succession in the botanical world. Florence and Cope Rheumatology Department and Sutton Rheumatism Research Laboratory, University of Sydney, Royal North Shore Hospital, St. Leonards, New South Wales, 2065, Australia. Manuscript received 8 November 1989; revised manuscript accepted 31 January 1990. CBMHIBCHM I Volume 7: 1990 I p. 77-91 78 W. WATSON BUCHANAN AND RODGER M. LAURENT HISTORICAL EVIDENCE OF THE DISEASE ~ n c i l n t Skeletons Several works have suggested that rheumatoid arthritis, if it is not a new disease, then certainly is one that was rare before 1800,' when it was first clearly des~ribed.~ Supporting this view is the surprisingly little evidence of the disease in ancient skeletal remain^.^ This is in contrast to clear examples of osteoarthritis, ankylosing spondylitis, diffuse idiopathic hyperostosis, gout, possible psoriatic arthritis, and even a case of ohron~s is .~ In many reports the joint changes are either atypical or there is insufficient detail to make a diagnosis of rheumatoid ar thr i t i~.~ The mummy described by May in 18976 is frequently cited as a typical example of rheumatoid arthritis, but we agree with Short7 that . the radiological changes are consistent with generalized osteoarthritis. Possible examples, however, of rheumatoid arthritis are one found in 400 Saxon and Romano-British skeletons by Rogers et and one of two cases found among 416 skeletal remains in a Roman cemetery in England by the two T h o ~ l d s . ~ The concept that rheumatoid arthritis may be a New World disease is supported by two recent studies of skeletal remains in Ohio Woodland Indians about 900 to 1,200 years old1° and in a group of skeletons 3,000 to 5,000 years old in North West Alabama" which have demonstrated changes suggestive of a symmetrical erosive polyarthritis. The authors comment that the nature of the severe erosive lesion seen in rheumatoid arthritis is such that they will not be identifiable after some time in the soil, becoming indistinguishable from artefactual damage. Therefore burial methods and soil type may have an important influence on skeletal preservation, and could be one reason for the lack of evidence in some countries of rheumatoid arthritis.12 Early Medical Literature l Short13 carefully reviewed ancient Roman and Greek medical writings, and concluded that Scribonius Largus, Julius Caesar's Chief Medical Officer, described a polyarthritis which occurred chiefly in elderly women. In addition, Aretaeus (A.D. 81-A.D. 138?) described a polyarthritis which could have been polyarticular gout, because the disease was characterized by long quiescent intervals between acute attacks "kindled up by any slight cause." Soranus of Ephesus (A.D. 98-A.D. 138) in his treatise On Chronic Disease described polyarthritis which was more common in middle-aged men, causing the joints to "become twisted, with the toes and fingers either turned sideways, or bent over backwards, or rest immovable upon their neighbors." However, as ShortI4 explained, the description includes an acute attack of gout with discharging tophi. Of course, the differentiation between chronic Rheumatoid Arthritis 79 tophaceous gouty arthritis and rheumatoid arthritis has always been difficult, even in the present era.15 Sturrock et a1.16 reviewed the early Indian medical writings in The Caraka Samhita of the first century A.D., and concluded that the description of deforming polyarthritis was consistent with a diagnosis of rheumatoid arthritis. 'Neither Short1' nor ourselves have been able to discover any medical writings with descriptions of rheumatoid arthritis until the seventeenth century, when Thomas Sydenham (1624-89) gave a fairly reasonable account.18 Possible descriptions were given by Musgrave,lg Oli~er,~O S a u v a g e ~ , ~ ~ and Heberden22 in the following century. Following the clear description by Landre-Beauvais (1774-1840) in Paris in 1800, a number of French and English physicians described23 and i l l~ s t r a t ed~~ the classical features of the disease as we know it today.25 Rheumatoid arthritis was only named in 1859 by the "Father of Rheumatology," Sir Alfred Baring Garrod (1819-1907).26 Juvenile rheumatoid arthritis was also described in the latter part of the last century27 including the classical paper by Sir George Frederick