Simon M. Helfgott, MD
“You will notice that there are many, many papers selected for today—we have 21—and you see a great many which are recorded by title only. It is unfortunate we cannot hear all of these papers.” —From the opening remarks of L. Maxwell Lockie MD, president of the American Rheumatism Association, addressing its Annual Scientific Meeting, Bethesda, Md. (1957)
In 1957, the Fourth Interim Scientific Session of the American Rheumatism Association (ARA; now the ACR) began inauspiciously with a December snowstorm. No doubt the 254 attendees had to scramble to find their way to the National Institutes of Health campus in a region of the country where traffic grinds to a halt whenever just a few snowflakes fall. Thankfully, our recent meetings in Washington D.C., were not marred by such adverse weather.
Realistically, holding a major event in December in the northeastern United States is asking for meteorological trouble. Falling temperatures, bone chilling winds, and precipitation that lands either as drenching rains, fluffy snow, black ice, or all of the above, are strong predictors for lowered attendance numbers. For the past few decades, our annual meetings have been held in either late October or early November, when the fading autumn sun can still provide some gentle warmth and the bright autumn colors have yet to fade. Before settling on this particular time of year, the ACR meetings used to be held in the spring, either late May or early June. However, springtime can serve up its own set of weather issues. With an average daily high of 92 degrees, San Antonio can get pretty hot in June. I wonder whether those sweltering days under the hot Texas sun during the 1993 convention convinced our leadership to move the annual meetings to autumn.
The Backbone of Rheumatology
Looking back at some of the earliest meetings of the ARA, we can see how much we have grown as a specialty. In reality, rheumatology has fairly shallow roots compared with other internal medicine specialties, such as cardiology or gastroenterology. Cardiologists have long recognized the physiologic underpinnings of cardiac auscultation, and gastroenterologists practicing in the early twentieth century understood the pathogenesis of some common digestive disorders and their clinical correlates. For example, aortic stenosis and cholecystitis were pretty well understood by clinicians for well over a century. In contrast, when seeing patients with musculoskeletal complaints, practitioners were often left to deal with a paucity of clinical clues coupled with a severely limited knowledge of their pathophysiology. It was Sir William Osler who once quipped that when a patient with arthritis comes through the front door, he runs through the back door!
There was a great challenge in defining the “rheumatic diseases.” The original definitions implied that they were related to the internal flow of abnormal humors, such as phlegm or black bile. Nowadays, when using the term, we often employ a circular argument, namely, “we know a rheumatic disease when we see one.” This may also be the case with other well-known monikers employed in our lexicon, such as collagen vascular disorder, connective tissue disease, and systemic lupus erythematosus. It seems that for the past 150 years, rheumatic diseases were often identified by using charming descriptors. Talk about wolves with red cheeks! Sometimes, the less than charming adjective “senile” was applied to a host of musculoskeletal ailments to emphasize their association with the aging process.
Neurologists took a different approach to naming diseases. They named many of their diseases after the person who was believed to have first described the condition. It seems that when rheumatology followed this path, more problems were created. While preparing an article about the history of vasculitis, Eric Matteson, MD, professor of medicine at the Mayo Clinic in Rochester, Minn., uncovered the truth about Friedrich Wegener’s Nazi past. And although he was convicted of war crimes, Hans Reiter’s name was used until recently to describe the well-known triad of arthritis, conjunctivitis, and urethritis. So much for honoring individuals.
Two Hundred Years of Confusion?
A timeline describing the scientific understanding of rheumatology might include four distinct eras. The first would be the Rheumatism Age, when every “rheumatic” affliction was attributed to rheumatic fever. Poor public hygiene allowed for the widespread dissemination of this infectious illness. The fact that a major manifestation of rheumatic fever is acute arthritis resulted in clinicians always considering rheumatic fever when evaluating any patient with joint pain.
The next phase of the timeline was the Description Era, when astute clinicians began to classify certain conditions as being unique diseases, unrelated to rheumatic fever. Though the names of the diseases demonstrated little understanding of the conditions, they allowed certain illnesses to begin to move away from the designation of rheumatic fever.
For example, there is lupus “the wolf,” polymyalgia rheumatica, and rheumatoid arthritis (RA). However, the latter two names seem to be efforts by the authors to hedge their bets. After all, isn’t the word “rheumatoid” simply an adjective for rheumatism? Following this period came the Enlightenment Era, when classification of rheumatologic diseases became more firmly established and therapy options moved beyond salicylates and the sparkling waters of the spa. This was a time when gold salt therapy emerged as a key treatment for RA and the development of corticosteroids was just over the horizon.
In New Orleans, never book a hotel next to or in the French Quarter, unless you like staying awake all night listening to jazz riffs punctuated by the not-so-occasional drunken brawl.
Two Hundred Years Of?
To commemorate its two hundredth year of publication, the New England Journal of Medicine (NEJM) recently posted a timeline and a documentary video of what their editors selected as the major breakthrough papers that have been published during this time (http://nejm200.nejm.org). Rheumatology fares poorly. There is just a single entry; “On stiff and painful shoulders: The anatomy of the subdeltoid or subacromial bursa and its clinical importance,” written by the noted orthopedic surgeon, E.A. Codman, MD, of the Massachusetts General Hospital (MGH) in Boston. This was considered to be the seminal paper published in NEJM in over two centuries!
Well, here are some of the other papers of interest that I found in the archives. There was “Colchicum in rheumatism,” an astute letter written in 1831 by a certain Mr. Tweedie of Guy’s Hospital in London, England, who discusses the benefits of using powdered colchicum root given every four hours for the treatment of rheumatism. It seems to lessen painful musculoskeletal symptoms but created other, quite familiar issues: “The stools are for the most part characteristic; they are of a peculiar loose, yellow nature, such as are seldom, I believe, seen under other circumstances.” Plus ça change, plus c’est la même chose.
In 1909, Robert B. Osgood, MD, another noted orthopedist (of Osgood-Schlatter disease fame) from MGH published a “state-of-the art” review, entitled, “Recent progress in the treatment of various conditions called rheumatism.” He reviews many of the ancient and more modern theories of rheumatism and rheumatic fever. We learn that bloodletting is so passé. The author also eagerly dismisses the work of a well-known figure at the time, Dr. Alexander Haig of England. Dr. Haig authored Uric Acid in the Causation of Disease, in 1903. This 900-page tome was published for six editions, so clearly there was an audience for his theories that explained most joint afflictions on a metabolic derangement of urate production.
What else was being published in the British literature? In 1899, there was a succinct review entitled, “Why people go to spas,” in Nature. This was the only article that I could find in the early archives of that venerable journal pertaining to arthritis.
However, around the same time, a shift in thinking occurred in England that had profound implications for what was to emerge as the field of rheumatology. In 1905, a committee was formed in Cambridge, England, to study the chronic joint diseases. Under the leadership of T.S.P. Strangeways, the Huddersfield lecturer in special pathology at Cambridge University in Cambridge, England, a serious effort was made to create some sense out of the chaos of early twentieth century clinical medicine by developing standardized methods of physical examination and data collection.
Fast forward another 30 years and one begins to see evidence of rheumatology developing into a more recognizable form. Two seminal papers were published; the first by Chester Keefer, MD, assistant professor of medicine at Harvard Medical School in Boston, on the etiology of chronic arthritis, followed by a review of the classification of arthritides by Walter Bauer, MD, associate professor at Harvard Medical School. Though primitive, these papers established classification criteria that would be readily recognizable by clinicians today. Around this time, the emergence of gold salt therapies as a viable treatment for RA was also being described by Forestier and others. Finally, rheumatology emerges from its cocoon.
The ARA Enters the Picture
So what were the topics discussed on that snowy December day in 1957? Three broad themes emerged; the first focused on the serological reactions that were being observed in patients with RA. The second series of presentations targeted the pathogenesis of lupus, focusing on complement activation and the newly described antinuclear antibodies. The third group consisted of papers discussing synovial membrane and cartilage metabolism. The authors included many investigators who became the leaders of our field: Henry Kunkel, Charles Christian, Edward Franklin, John Vaughan, and Morris Ziff, to name just a few. It must have been great for all 224 attendees to sit altogether and hear these cutting-edge presentations. They were, after all, a captive audience. There were no concurrent sessions, posters to read, or exhibits to attend that could compete for their attention. And the snow that was falling outside presumably kept them inside. I doubt that the NIH owned any snowplows!
Over the next twenty years, attendance at our national meetings hovered around 1,000 attendees. By 1980, attendance had risen to 2,500 conferees, and this number doubled by the end of the decade. The next big leap in the numbers occurred in 1999, when a record 10,000 people in Boston heard about the introduction of biological therapies for the treatment of RA. I recall the buzz at some of the standing-room-only plenary sessions held in the Hynes auditorium on Newbury Street. It was not just the clinicians who were keen to learn more about the anti–tumor necrosis factor therapies. The room was swarming with financial analysts who clearly had strong financial incentives to be there. Many keep returning year after year to hear more about our diseases and their treatments.
Since 1996, attendance at the ACR national meetings has climbed by 50%, an amazing statistic considering the fact that the census of U.S. rheumatologists has remained fairly static over this time. The rising numbers confirm the worldwide interest that our specialty has garnered. It is also a tribute to the growing number of our colleagues working in the allied rheumatology health professions who have created their own wonderful conference within a conference.
What Has Changed and What Has Not
The Washington, D.C, meeting was a great success. Some things stay the same. The state-of-the-art reviews are first rate, there is an endless list of choices for the Meet-the-Professor sessions, and the diverse selection of podium and poster presentations provide the audience with a wide view of the current state of rheumatology. We have increased the original 21 presentations of the 1957 annual meeting by over a hundredfold.
There is also the social side of the meetings, when we get the chance to share a meal or have a drink with some old (and aging!) acquaintances and former colleagues. It’s fun to relax in one of the lounge areas with a cup of coffee and eavesdrop on a conversation in one of the many languages spoken at the ACR meetings.
There are also some things that have changed for the better. You don’t need those heavy abstract books that had to be schlepped around to keep up with the meeting. No longer do we need to stare at a television monitor scrolling a list of names of attendees who had messages waiting for them at the message center. The days have passed when we needed to stand in lengthy lines at a bank of desktop computers to get three minutes to check our e-mail messages. Now we can go online anywhere to search abstracts, track our CME credits, and check out the buzz on the ACR Facebook page. The next iteration of technology has laptops being replaced by smartphones and tablet devices. Messaging is surpassing e-mail as a means of communication. Some of you are avid Twitterers and you may have tweeted about the meeting using the hashtag #ACR2012. What a great way to let others know where the buzz is biggest, using 140 characters or less. If you haven’t yet tweeted, consider doing so before next year’s meeting in San Diego. Only twits don’t tweet.
Some Dos and Don’ts for ACR/ARHP Meetings
- Be careful where you sit, especially if you are about to give a podium presentation. A few minutes before I was going to speak at the 1985 plenary session, I had the misfortune of sitting on a piece of gum that someone may have “accidentally” placed on a chair. Too late for me to do anything except to walk up the stairs sideways!
- I was once told to carry a spare slide projector bulb in case the projector that you were about to use was in desperate need of one. Spare bulbs were not easily found at convention centers and so the chances were great that your talk and the others to follow would either be cancelled or postponed. This advice once saved me, big time, from disaster. Now that we use PowerPoint, I suggest carrying one, if not two, memory sticks (as a backup to your backup!).
- In New Orleans, never book a hotel next to or in the French Quarter, unless you like staying awake all night listening to jazz riffs punctuated by the not-so-occasional drunken brawl.
- If traveling with young children, always pack their favorite drinks. Many years ago, at one of the most popular annual industry-sponsored events that highlighted the great wines and produce of Sonoma, my 3-year-old son demanded a box of apple juice. Though the wine bars carried $50 bottles of every major vintage, sadly, there were no juices. Not wanting to be charged with providing alcohol to a minor, I spent the next hour walking in all directions trying to purchase a suitable juice box. I succeeded, but by the time I returned all the great food had been consumed and only the cheaper wines remained.
- Always, always carry your poster on your flight. Never let the airlines check it as baggage even if you are taking a direct, nonstop flight to the event. Trust me, I know this fact.
Dr. Helfgott is physician editor of The Rheumatologist and associate professor of medicine in the division of rheumatology, immunology, and allergy at Harvard Medical School in Boston.
