William S. Clark, first editor ofArthritis and Rheumatism

The birth of Arthritis and Rheumatism (A&R) was not easy. The idea of a journal of the American Rheumatism Association (ARA), the precursor of the American College of Rheumatology, was discussed repeatedly. At one time, members of the editorial staff of the British publication Annals of the Rheumatic Diseases courted members of the ARA to adopt their journal as the official publication of the association (1). In 1948 Robert M. Stecher, president of the ARA, urged, “The time has come when this Association must establish a journal of its own” (1). The debate about a new publication continued. Some ARA members recommended that advances in rheumatic diseases should be published in journals with wide readership to acquaint physicians with progress in this field of medicine. A committee, established to consider the publication of a journal of the ARA, recommended to the Executive Committee to proceed with the journal. The decision was further delayed. A poll of the ARA members was conducted in 1955 and the majority favored the publication of an official journal of the association. Finally, in 1957 the Executive Committee and membership of the ARA approved the publication of the new journal, named Arthritis and Rheumatism, Official Journal of the American Rheumatism Association. William S. Clark (Figure 1), an ardent supporter of a journal for the ARA, was appointed its first Editor during the ninth International Congress on Rheumatic Diseases in June of 1957 in Toronto, Canada. William S. Clark, Editor of Arthritis and Rheumatism, 1958–1965. The first issue of Arthritis and Rheumatism was printed in February 1958. The publisher, Grune & Stratton, presented Dr. Clark with a special copy of the inaugural issue with the list of the contents omitted from the cover (Figure 2). Mrs. Clark had designed the cover of A&R during a celebration announcing Dr. Clark's appointment as the first Editor. She chose red and black because she only had a red lipstick and a black eyebrow pencil in her purse at that time. The cover design and colors were changed after 13 years, starting with the January 1970 issue. Cover of the first issue of Arthritis and Rheumatism presented by the publisher to William S. Clark, the first Editor. The table of contents was omitted from the cover of this special copy. In that first issue, William Clark's editorial stated, “Research in arthritis and rheumatism has no boundaries or preconceived limits of pertinent inquiry” (2). The 50 years of progress in science and patient care that have been published in the pages of A&R amply confirm this prediction. In 1958 the vocabulary relevant to rheumatic diseases did not include lymphokines, cytokines, genomics, proteomics, etc. The therapeutic armamentarium for rheumatoid arthritis (RA) was quite limited. The concept of monoclonal antibodies, partially or totally humanized, had not yet been developed. The era of carefully controlled therapeutic trials was beginning to awaken. The statement that research in arthritis and rheumatism has no boundaries will undoubtedly be equally true for the next 50 years. Only our imagination may approximate the future discoveries and findings that will be published in the pages of Arthritis and Rheumatism. In this same editorial, William Clark also predicted that A&R “… will almost certainly become a highly significant medium of the exchange of scientific information among those concerned with the cause and cure of rheumatism and for keeping interested physicians and scientists informed of important developments in this field” (2). This prediction without doubt has been fulfilled in that A&R has become the premier publication in the field nationally and internationally. Contributors of scientific and therapeutic advances throughout the world submit and publish their works in the journal. The first and subsequent Editors, along with the editorial boards, have maintained a high standard for accepting articles in basic and clinical sciences in rheumatology. Initially, papers originated primarily within the United States. Now, however, high caliber contributions come from many parts of the world. The journal is read in many nations and is considered the most desirable journal for publication of advances in the field. During Dr. Clark's 8-year tenure as Editor, A&R published six issues per year. In its first 3 years of publication, the journal contained a little less than 600 pages per year. As its popularity increased, the annual page allocation was increased by the publisher. The eighth volume, the last year of William Clark's editorship, consisted of 1,165 pages. William Clark and the ARA Committee for Publication selected able and distinguished Assistant Editors, including Ralph J. Wedgwood, Ronald W. Lamont-Havers, Baruch S. Blumberg, Charles L. Christian, and Daniel J. McCarty (Editor Elect). Ralph Wedgwood became Professor and Chairman of the Department of Pediatrics at the University of Washington. Ronald Lamont-Havers served in several positions at the National Institutes of Health, culminating in his appointment as Deputy Director of all the Institutes in 1974. Baruch Blumberg received the 1976 Nobel Prize in Physiology and Medicine for his discovery of the hepatitis B virus. Charles Christian and Daniel McCarty later served as Editors of Arthritis and Rheumatism and as Presidents of the American Rheumatism Association. Dr. Clark resigned the Editor position when he became the President of the Arthritis Foundation in 1965. The first eight volumes of Arthritis and Rheumatism established the foundation for the future of the journal. Dr. Clark won the support of the publisher and the trust of an increasing number of authors who submitted their discoveries and observations for publication. Many original laboratory studies, clinical investigations, and observational studies were recorded in the pages of A&R. We will never know which single article William Clark would have considered as the most outstanding work during his editorship. However, in reviewing the content of these eight volumes of A&R and consulting several issues of the Science Citation Index, one article stands out for having a lasting impact in rheumatology and on the American Rheumatism Association: “1958 Revision of Diagnostic Criteria for Rheumatoid Arthritis,” authored by a Committee of the ARA whose members were Marion W. Ropes (Chairwoman), Granville A. Bennett, Sidney Cobb, Ralph Jacox, and Ralph A. Jessar (3). This work was also published in the Bulletin on the Rheumatic Diseases (4). During a 1954 meeting of the ARA, the need for developing diagnostic criteria for RA was discussed. A committee was appointed to examine the issue and to prepare recommendations. The committee consisted of the five individuals who authored the 1958 revised criteria cited above. Sidney Cobb, a member of the committee, later described how the committee formulated the preliminary criteria (5). Initially, the committee prepared a list of all the clinical manifestations but discarded a number of symptoms and signs for lack of discriminating RA from other rheumatic conditions. Early in the deliberations the committee agreed to create categories of disease severity including “definite,” “probable,” and “possible” RA. The rationale for the “definite” category was to include only patients who without question have the disease, but with the understanding that some patients with the disease would be excluded from this category. It was also reasoned that the “possible” category should include relatively few patients who have RA and a large number of patients who may or may not evolve into possible or definite RA. The preliminary criteria were published in 1956 with the understanding that after 2 years of clinical evaluations, the criteria would be reviewed and revised (6). After the results were reviewed, the category of “classical” RA was added, requiring that the duration of joint symptoms and signs listed in the criteria one through five must be continuous for at least 6 weeks. In addition, seven of the 11 criteria must be present. For the diagnosis of “definite” RA, five of the 11 criteria were required and the joint symptoms and signs must be present continuously for at least 6 weeks. For the “possible” category, three of the 11 criteria were required, and among the five symptoms and signs, at least one must be continuous for at least 6 weeks. The diagnosis of “probable” RA required two of the 11 criteria and the duration of joint symptoms must be at least 3 weeks. The 1958 revision of the diagnostic criteria also listed 20 exclusions. It is of interest to note how the clinical material was collected for identification of the diagnostic criteria. First, some case materials had been stored on punch cards from a study in Pittsburgh. Second, the committee requested from physicians known to be interested in rheumatic diseases, who were located in 19 cities, to provide detailed clinical information on five of their most recent patients with definite RA, five most recent patients with probable RA, and five most recent patients with no evidence of RA. Of the information received, 332 suitable cases were identified for further analysis. In his concluding remarks Sydney Cobb noted “In addition, after going through the laborious analysis of this mass of data, using only the simple IBM counting sorter to prepare selected cross tabulations, the value of high speed computing equipment was impressed on us” (6). The 1958 revision of the diagnostic criteria for rheumatoid arthritis was widely used for almost 30 years. These criteria were employed for selection of patients enrolled in therapeutic trials. Specimens used to study disease mechanisms were obtained from patients who satisfied the criteria for classical or definite RA. In the teaching of medical students, residents, and postdoctoral fellows, the diagnostic criteria became the foundation for recognizing RA. Undoubtedly, these diagnostic criteria influenced practicing physicians for many years. As clinical sciences evolved over the decades, it became clear that the criteria for the diagnosis of RA needed to be reassessed and modified. A new committee was appointed in 1983, and the 1987 revised criteria were published in March 1988 (7). In the new criteria the categories of classical, definite, and probable RA were omitted. The number of criteria was reduced to seven, omitting the invasive criteria and modifying the required symptoms and signs of joint involvement. All the exclusion criteria were omitted. William S. Clark (1914–1996) was a physician, educator, administrator, and always an optimist. His career began in general medical practice, followed by a 1-year pathology fellowship. He was then accepted for a fellowship in rheumatology with Dr. Walter Bauer at the Massachusetts General Hospital, 1945–1948, and remained at that institution until 1953. He was then recruited to the faculty of the Western Reserve University School of Medicine in Cleveland, Ohio to be the first director of the program in rheumatic diseases. While editor of Arthritis and Rheumatism, William Clark was appointed Medical Director of the National Foundation in 1958, formerly the March of Dimes, when the National Foundation expanded its programs from poliomyelitis had been established in 1948 to support arthritis research, education, and patient care. In 1964 the Arthritis and Rheumatism Foundation reorganized and became the Arthritis Foundation, and Dr. Clark served as its first president from 1965 through 1970. Thereafter, he resumed the practice of rheumatology but soon became Director of the Department of Medicine at St. Luke's Hospital in New York City. The field of rheumatology gained much through the leadership positions Dr. Clark held during his career. I owe personal thanks to William Clark. He served as my mentor during my thesis work at the Western Reserve University School of Medicine and he guided me to a rewarding career in rheumatology.

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