- Indian Rheumatology association
Being a rheumatologist is much more fascinating and simpler in today’s era. The work of our predecessors and various researchers over the past several decades, has provided us with a plethora of advanced diagnostic tests, DMARDs, biologicals, and various treatment strategies to treat even the trickiest and most refractory of the cases. However, the practice of rheumatology was much different from today before the advent of biologicals and this was just 20 years back! Imagining what rheumatology was like in the early 20th century would make most of us want to reconsider being a rheumatologist in those times. Most of the NSAIDs used today remained undiscovered. Aspirin was the only drug available as anti-inflammatory therapy. DMARDs, GCs and antibiotics were not known. Patients with systemic diseases like vasculitis and CTDs, either remained undiagnosed or at the mercy of the natural course of their disease. Even the term rheumatology was not used until the 1940s. Hence, it was a completely different world, a glimpse of which would be an interesting vision to follow.
Thanks to a ‘Letter to the Editor’ in the journal ‘Rheumatology Forum 2022’, which discussed the ‘10th Summer medical course proceedings of the Congress of Polish Society against Rheumatism’, we have some interesting insights into the ‘Diagnosis and Therapy of Musculoskeletal disease’ as it was called then. It was interesting to see that a separate conference on the topic at that time meant that rheumatology was recognized as an independent specialty to focus on, even at that time. Within these proceedings, the authors acknowledged the complex etiology of musculoskeletal diseases which was unknown and incompletely understood, something that holds true even today. Articular changes were considered a mere reaction of the musculoskeletal system to general diseases. Quoting from Dr Elenora Reicher (Assistant professor in University of Warsaw, 1937): “Joint disease in most cases is merely a reaction of the system to a pathogenic stimulus affecting the whole organism, while the joint reaction depends on the nature of the stimulus – which is either infectious or dependent on endocrine disruption or caused by mechanical loads or joint alignment.”
Constrained by the resources of their time, therapeutic approaches mainly included bed rest (for acute conditions) and analgesics (administration of sodium salicylate, aminophenazone known as pyramidon, aspirin that is acetylsalicylic acid, and phenazine or antipyrine). Most of these drugs are not used today due to their toxic profile and availability of safer NSAIDs. Gold salts and colchicine were described as experimental therapies. Other therapies described for chronic diseases included stimulus treatment (consisting of injecting milk and its unknown derived products), autohemotherapy (intramuscular administration of the patient’s own blood). Removal of inflammatory foci like tonsils was a popular method of practice. You would be surprised by the dose of salicylic acid recommended for use in arthritis patients i.e. up to 10-15g /day as compared to 75mg used in cardiac patients today. It was often combined with calcium bicarbonate to reduce gastric irritation. Forced diuresis by excessive consumption of fluids was commonly advised and continued for long periods.
Classification of rheumatic diseases was much different than today. The polish society at that time had classified arthritis into 8 groups: polyarthritis infectiosa acute (acute arthritis by infectious agents), polyarthritis infectiosa chronica (chronic arthritis by infectious agents), polyarthritis chronica primaria (mostly RA like diseases), polyarthritis non infectiosa (arthritis due to non-infectious causes like post traumatic), arthroso-arthritis metabolica, osteoarthritis, spondylosis and arhroso-arhritis climacterica (soft tissue rheumatisms). You would be surprised to know that RA was one of the most dreaded forms of arthritis, because symptoms were persistent and there was no treatment. Imagine trying to manage RA with NSAIDs alone! Perception of physicians regarding RA is better reflected from a quote by Dr Reicher herself: “it is one of the most severe, most persistent rheumatic disorders, and one of the most difficult tasks for a physician”.
With medical advancements, our job as a rheumatologist has become much easier in many aspects when we compare with 100 years ago, but we have our own set of problems and challenges adapted to the modern world. It would be interesting to see how the future historians (100 years from now) would perceive rheumatology in the present day and how fascinated they would be reading about it.
I would like to acknowledge the contribution of Dr Pranesh V, 3rd year Resident, Department of Medicine for his invaluable inputs towards writing this article.
