• Osteoarthritis
• Arthritis
• Arthritis, Rheumatoid

EULAR is celebrating its 75-year anniversary after the foundation in 1947. ARD is contributing to this celebration by presenting a series of previously published articles that highlight the development of rheumatology over these 75 years. Comments to the first four selected papers published in 1947 appear in this issue.

Importantly, one of these papers presents a brief report from the first European congress of rheumatology, held in Copenhagen in 1947. It is, therefore, also important that the anniversary congress in 2022 is organised in the same city. The foundation of EULAR in 1947 is also described in the introduction to this report. At that time, the International League against Rheumatism (ILAR) was the global umbrella organisation and a European section was formed ‘on the same lines as the Pan-American section established during the war’. Later, ILAR also included the Asian and Pacific League against Rheumatism and the African League. ILAR organised separate international congresses, the last in Edmonton in 2001, and its organisation, role and by-laws were changed around 2006. Today, each of these four ‘leagues’ is organising their own congress, in addition to the congress organised by the American College of Rheumatology (ACR).

The congress report illustrates that the rheumatologists also at that time had a broad focus on musculoskeletal diseases, even if some topics will not be recognised as important by younger rheumatologists today, for example, antistreptolysin antibodies. It is also mentioned that a full session addressed treatment of rheumatoid arthritis (RA) by gold salts and chemotherapy, and that ‘new work reported by Svartz (Sweden) on treatment of arthritis with sulphonamides still awaits confirmation’. Professor Nanna Svartz developed sulphasalazine, which is still used in the treatment of RA and of spondyoloarthritis with peripheral joint involvement.

George D. Steven published another interesting paper in 1947 with the title ‘X-ray appearances in chronic rheumatism’.1 The main focus of this paper was RA, osteoarthritis (OA) and gout. Many of the imaging findings that we also focus on today are described, like cartilage loss and bone erosions in RA. However, the opportunity for using scoring systems for evaluation of radiographic progression is not mentioned, which is perhaps not surprising since the scoring systems in RA and OA first were published in the 1971 and in 1957, respectively.2 3

This paper also includes a section called ‘Differential Features in Other Diseases’. The first part of this section focuses on ankylosing spondylitis (AS), but very briefly. My interpretation is that AS was not recognised as an important disease to the same extent as RA, OA and gout at that time, and the description of radiographic abnormalities in AS is less detailed and accurate compared with current knowledge. Interestingly, Dr George D. Steven worked at the famous Royal National Hospital for Rheumatic Diseases in Bath, UK, which later became a leading institution for research in AS under the leadership of Andrei Calin. Some of the major advances from his research were the development of the patient-reported outcome measures Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and other important measures for this disease.4

Another very interesting contribution is the proceedings from the American Rheumatism Association (now called ACR) meeting in 1946. These proceedings cover more than 50 pages. Many famous rheumatologists at that time gave their presentation followed by discussion which is also included. Readers may be surprised to see that these proceedings were published in ARD and not in arthritis and rheumatology (previously arthritis and rheumatism), the official journal of ACR, but the first issue of this journal was published as late as 1958.

When reading these proceedings, it becomes very clear how rheumatology has developed during the last 75 years. Classification criteria for the various rheumatic diseases were non- existing 75 years ago, and most of the presentations were reporting case series and most of the research seemed to come from health services connected to the armed forces during and just after the second world war. Furthermore, access to therapies was poor. In his speech, the congress president, W Paul Holbrook, highlighted the need for strengthening the work in public relations and also raise awareness of rheumatic diseases among general practitioners. These topics are still very relevant today.

I was unable to find any information about rheumatoid factor, which was discovered by Erik Waaler in 1937.5 It may have happened that this discovery had not fully disseminated to and accepted by US rheumatologists because of the war.

Philip S. Hench—the discoverer of glucocorticoids and subsequent Nobel Prize recipient—gave a talk on rheumatic diseases among American soldiers in world war II. He divided the diseases into those peculiar to war and military services and those coincidental to war and military service. In this second group, he included recurrences or exacerbations of pre-existing rheumatic diseases such as rheumatic fever, RA, fibrositis, gout, etc as well as certain diseases that had their onset while the soldier was under no special stress, for example, RA and osteoarthritis. Gonorrhoeal arthritis was also especially mentioned. Dr. Hench also tried to make some estimates about incidences, and also about incidences related to geographic service of the soldiers.

Fibrositis was discussed in several presentations during the congress and was considered as a frequently occurring rheumatic disease.

Otto Steinbrocker, who published his famous functional classification criteria in 1949,6 gave a presentation on painful homolateral disability of shoulder and hand with swelling and atrophy of the hand. I mention this presentation also as an example of the broad focus on various musculoskeletal diseases at the conference.

I mentioned fibrositis above. My understanding is that this term was referring to a clinical picture very similar to what we today call fibromyalgia. I also recall that fibrositis was used in Norway in the 1970s and early 1980s before the term fibromyalgia was commonly used.

In his presentation during the congress, Dr Philip Hench also briefly discussed the differentiation of psychogenic rheumatism from fibrositis. In the fourth selected paper,7 this topic is elaborated in detail. The author, Dr. Edward W Boland, lists several disorders that are recognised as psychosomatic but states that physicians are not so familiar with the fact that disabilities of the locomotor system frequently result from psychic causes. He excludes RA as a psychosomatic disease and defines psychogenic rheumatism as the musculoskeletal expression of functional disorders, tension states or psychoneurosis. He also emphasises that the diagnosis of psychogenic rheumatism is not merely made by excluding organic disease but that positive evidence for psychoneurosis must also be established.

He also presents a comprehensive table to differentiate psychogenic rheumatism from primary fibrositis. I think it is interesting that this topic was addressed already 75 years ago, and that the debate is still ongoing regarding this topic.

In conclusion, I think these four papers, published in ARD 75 years ago, highlight the enormous development that we have faced over these years, both regarding disease classification, diagnosis and management. However, interestingly, many of the problems we still face today have already been recognised when EULAR was founded and some have remained unresolved, awaiting finalisation of pertinent research activities and therapeutic resolution. This illustrates that we should be grateful to the heroes that pioneered research and development in rheumatology. We may also be grateful to ARD for presenting all these important studies and reports and representing rheumatology research as the first ever rheumatology journal into today and to EULAR for fostering presentations and discussions of the latest advances in our field.