Evidence of arthritic damage to the bones has
existed for thousands of years. There is evidence of osteoarthritis
in neolithic burial sites, in Egyptian mummies, and in Roman skeletons,
but skeletal evidence of rheumatoid arthritis (RA) outside of the
New World is lacking during these early periods. Investigation by
paleopathologists into the skeletal remains of Native Americans suggests
that RA existed in the New World prior to the voyages of Columbus,
and possibly before the earlier voyages of the Vikings. Evidence suggests
that RA has existed in the New World since 4000 BC, however, there
is sparse evidence that the disease occurred in Europe before the
17th century or in Africa before the 20th century.6865
There are, however, several credible reports
that suggest that RA may have existed in Europe much earlier than
previously thought. Fontecchio, et al., reported that a female mummy
(aged 50 - 55) was discovered at the Basilica of St. Francesco, Italy,
and has been dated to the late 1500s. This mummy shows many pathological
changes peculiar to RA, including large erosions and evident subluxation
of the metacarpophalangeal joints of the hands, lateral deviation
of all the fingers with typical “z” deformation Z-Thumb Deformity,
Fig.1019 of the thumbs, partial overlapping and fibular
deviation of the toes, and severe erosion of the right humerus head,
but no involvement of the sacroiliac articulation, a prominent manifestation
of ankylosing spondylitis. Human leukocytic antigens-DRB Genetic Factors in Pathophysiology typing was performed by these researchers on DNA obtained
from tissue sections and from the bones of this mummified subject.
Alleles consistent with RA in contemporary Mediterranean patients,
including Italians, were confirmed. The authors concluded that positivity
for the DRB1*0101 allele in an Italian Renaissance mummy with clear
skeletal deformities were suggestive of RA, suggesting that this disease
was present in the Old World shortly after the discovery of America
by Columbus in 1492, and 200 years before the first clinical diagnosis
worked out by Landré-Beauvais (1772-1840) in 1800.6844,10208
Asthenic Gout, the First Medical Description
of RA: A dissertation presented in 1800 by Landré-Beauvais
for his medical doctorate is the first medical description of RA.
After reviewing the main features of ordinary or regular gout, Landré-Beauvais
points out that the disease he called asthenic gout in 9 patients
who were long-term residents of the Salpêtrière hospice
in Paris who exhibited several distinctive features including predominance
in , females, a chronic course, involvement of many joints from the
onset, and a decline in general health. Landré-Beauvais described the influence of psychological factors
in the disease, the need for gentle treatments, and the inappropriateness
of bloodletting—all part of the accepted treatments for gout
at this time.4503 The
term "rheumatoid arthritis" was coined in 1858 by Garrod (1819-1907).
RA appears to have been prevalent in the New
World several millennia before its first appearance in Old World Europe.
The destructive changes suggestive of arthritis, which are evident
in the bones of ancient Native American of Tennessee, Alabama, and
the Ohio woodlands (more than 4,000 years ago), are indistinguishable
from those changes seen in contemporary RA. The female predominance
seen in these archaeological specimens (3:1), the erosive nature of
bone involvement, the radiographic appearance of the erosions, and
the symmetrical distribution of joint involvement are identical to
that found in living patients with RA. Although numerous skeletal
irregularities suggestive of RA have been documented in prehistoric
North American remains, no such irregularities have been found in
Old World skeletal remains during this same period. The erosive arthritis,
described by professor Rothschild occurring in archaic Native Americans,
affected the joints in a symmetrical fashion, involved the metacarpophalangeal
Fig.2688 metatarsophalangeal, proximal interphalangeal, and carpal joints,
but spared the distal interphalangeal joints.6832,6931,6939 Rothschild, et al., reported an analysis of 688 skeletons
from various European sites, ranging from as early as the Bronze Age
to the Black Plague epidemic of 1485-1486, and reported that erosive
disease was uncommon and always oligo-articular in distribution.6932
RA possibly began as a disease of the Native
Americans , who, to this day, are still highly predisposed to this
potentially devastating disease. The early adoption of the habit of
smoking among this population may have contributed to its earliest
appearance in Native Americans. Smoking was an established habit among
the New World Native Americans at the time of the first voyage of
Christopher Columbus in 1492,10162 and the habit has been associated with an increased risk
of developing the disease in genetically predisposed individuals.
The prevalence of the disease today is much higher in the Native Americans
population than the rest of the US population, or versus most other
population groups worldwide. Rothschild stated that the study of over
20,000 skeletons has identified the pattern of the spread of RA within
North America, and subsequently, its apparent export to Europe. Writing
in the Journal of Rheumatology in 2003, Rothschild,
et al., concluded that there was an inverse relationship between the
occurrence of tuberculosis (TB) and RA in the Archaic and Early Woodland
periods of North America. The authors stated that TB infection may
potentially provide protection against the development of RA because
osseous pathologies in skeletal samples from western Tennessee, indicative
of TB infection, were found only outside the rheumatoid catchment
area, (P<0.0001) but were frequently
found in burial catchment areas where skeletal evidence of TB was
found, but not RA. Archeological evidence suggests that RA was confined
to a very small area of what is today northwestern Alabama, southwestern
Kentucky, and west-central Tennessee in the Archaic period (5000-500
BC), with a minor spread to an area that today encompasses Ohio during
the Woodland period (500 BC to 1000 AD), and an explosive spread of
the disease after the late 18th century.10569,10651 In
the Old World, descriptions of symptoms suggestive of RA are extremely
rare before the 1600s, and researchers believe the disease may have
spread across the Atlantic with the advent of ships during the Age
of Exploration.6832,6865,6931,6939,11081
The first known skeletal evidence of RA has been
dated to as early as 4500 BC. Written descriptions of symptoms suggestive
of the disease did not appear until thousands of years later. A text
dated 123 AD first describes symptoms that are suggestive of RA. In
1859 the disease acquired its current name. The Flemish artist Rubens
(1577-1640) may have first graphically depicted the effects of RA.
Analysis of the hands in paintings attributed to Rubens during the
last 30 years of his life show progressive changes suggestive of RA.10421 This
may substantiate that RA was present in Europe in the early 1600s,
2 centuries before many modern authors date its appearance.
Dequeker and Rico noted in the Journal
of the American Medical Association that hand deformities
resembling those of RA were depicted in a painting representing the
temptation of Saint Anthony by an anonymous artist of the Flemish-Dutch
School in the mid-15th to early 16th century. The highly detailed
painting depicts wrist luxation, finger contractures, and ulnar deviation.
The painting now hangs in the Escorial Museum near Madrid, Spain.
The authors concluded that, like other earlier observations of rheumatoid
deformities in paintings of the Middle Ages, this is evidence that
RA is not a modern disease, and that it appeared several centuries
before Landré-Beauvais’ first description in 1800.10534
Alarcon-Segovia, Laffon, and Alcocer-Varela also
concluded that depictions of rheumatoid hands in Flemish paintings
of the 15th through 18th centuries supported an earlier date for the
first European appearance of the disease. The authors also stated
that the date of the first description of juvenile rheumatoid arthritis
(JRA), which is attributed to Cornil in 1864, is also in question.
The authors concluded that the painting Portrait of a Youth, which was painted in 1483 by the Florentine artist Botticelli (1445-1510),
had features of RA in the hand of the subject, who would be young
enough to be considered as having juvenile arthritis.6869
The authors further stated that in the fresco
representing Saint Augustine in his Studio, which
is in the church of Ognissanti in Florence, Italy (where Botticelli
is buried), there is clear evidence of arthritis in the fingers of
the saint. They further assert that the apparent swelling of the joints Soft Tissue Swelling and Juxta-Articular Osteoporosis in the paintings of Botticelli could not be ascribed to faulty
artistic technique because Botticelli’s art was based on fine
detail and that he was the greatest artist of linear design Europe
has ever known.
Not only has the appearance of RA varied temporally,
but also geographically as well. Epidemiological studies currently
suggest a decreasing incidence of RA in the United States and Western
Europe, and a rising incidence in Africa. In Caucasian populations
of Europe and America, the prevalence of RA Prevalence of Rheumatoid Arthritis is approximately 1%, and the incidence of RA Incidence of Rheumatoid Arthritis is 0.03%. Significantly higher rates are found among the
— U.S. Native Americans (although these rates appear to be
falling) and significantly lower rates in some Asian and African populations.6824,6865
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J Rheumatol.
2003;30(10):2095-2102.
Woods RJ, Rothschild BM. Population analysis of symmetrical erosive
arthritis in Ohio Woodland Indians (1200 years ago).
J Rheumatol.
1988;15(8):1258-1263.
Landré-Beauvais AJ. The first description of rheumatoid arthritis.
Unabridged text of the doctoral dissertation presented in 1800.
Joint Bone Spine.
2001;68(2):130-143.
van Vugt RM, Derksen RH, Kater L, et al. Deforming arthropathy or
lupus and rhupus hands in systemic lupus erythematosus.
Ann
Rheum Dis
. 1998;57(9):540-544.
Jacobsson LT, Hanson RL, Knowler WC, et al. Decreasing incidence
and prevalence of rheumatoid arthritis in Pima Indians over a twenty-five-year
period.
Arthritis Rheum
. 1994;37(8):1158-1165.
Rothschild BM, Woods RJ. Symmetrical erosive disease in Archaic Indians:
the origin of rheumatoid arthritis in the New World?
Semin
Arthritis Rheum.
1990;19(5):278-284.
Ciranni R, Garbini F, Neri E, Melai L, Giusti L, Fornaciari G. The
"Braids Lady" of Arezzo: a case of rheumatoid arthritis in a 16th
century mummy.
Clin Exp Rheumatol.
2002;20(6):745-752.
Abdel-Nasser AM, Rasker JJ, Valkenburg HA. Epidemiological and clinical
aspects relating to the variability of rheumatoid arthritis.
Semin Arthritis Rheum.
1997;27(2):123-140.
Rothschild BM, Coppa A, Petrone PP. "Like a virgin": Absence of rheumatoid
arthritis and treponematosis, good sanitation and only rare gout in
Italy prior to the 15th century.
Reumatismo.
2004;56(1):61-66.
Rothschild BM, Turner KR, DeLuca M. Symmetrical erosive peripheral
polyarthritis in the Late Archaic Period of Alabama.
Science.
1988;241(4872):1498-1501.
Fontecchio G, Ventura L, Azzarone R, Fioroni MA, Fornaciari G, Papola
F. HLA-DRB genotyping of an Italian mummy from the 16th century with
signs of rheumatoid arthritis.
Ann Rheum Dis.
2006;65(12):1676-1677.
Rothschild BM, Rothschild C, Helbling M. Unified theory of the origins
of erosive arthritis: conditioning as a protective/directing mechanism?
J Rheumatol.
2003;30(10):2095-2102.
Woods RJ, Rothschild BM. Population analysis of symmetrical erosive
arthritis in Ohio Woodland Indians (1200 years ago).
J Rheumatol.
1988;15(8):1258-1263.
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