Scores of residents willingly allowed Lawrence to question them in depth and systematically examine their joints, literally from head to toe. They also agreed to give a sample of blood and be comprehensively X-rayed whether or not they had any joint pains. The data from these surveys, analysed by hand, altered our understanding of the frequency and origins of the different forms of arthritis. Anxieties about radiation exposure and changing attitudes to public participation in research mean that such studies will never be repeated.
It was Lawrence's chief, Professor J.H. Kellgren, who had the vision to initiate this work. Kellgren, the first professor of rheumatology in the United Kingdom, provided the leadership and support which, with Lawrence's patient attention to detail, made them a formidable partnership. Their initial surveys were of musculoskeletal complaints in coal miners in the late 1940s. Subsequently, in 1954, Kellgren successfully established the Field Survey Unit at Manchester University, funded by the Empire Rheumatism Council (now the Arthritis and Rheumatism Council). Law-rence, then a lecturer in occupational health, was the obvious choice to be its first Director. This unit is still in existence over 40 years later, an almost unique achievement in any area of epidemiology (the study of how diseases occur in populations).
Kellgren and Lawrence's early radiographic surveys showed, for the first time, how common osteoarthritis (the degenerative arthritis of ageing) was, with few individuals escaping. They realised that reading X-rays was subjective, resulting in differences in interpretation between even experienced viewers. It was therefore necessary to standardise the reading of X-rays for the presence and grading of arthritis. Kellgren and Lawrence therefore produced an Atlas of Standard Radiographs (1963), which remains the only internationally agreed scheme in common use. An investigator presenting data at an international meeting today is still likely to be asked whether the patients' X-rays studied satisfy "K&L grade 2 or 3".
Based on studies in the 1950s and early 1960s, Lawrence also demonstrated the link between osteoarthritis and obesity, with a clear gradient of increasing risk of arthritis of weight- bearing joints, particularly the knee, with increasing weight. Mechanically this association made sense. It did however emphasise that osteoarthritis was not a consequence of ageing and was, potentially at least, modifiable by an alteration in lifestyle. The problem is that neither Lawrence nor his successors have succeeded in changing public behaviour.
Lawrence's principal fascination was with genetics. His work on genetics was not based on DNA and molecular biology but on the careful clinical study of affected individuals and their families. He compared the characteristics of such families with those he had observed in the general population and calculated what he believed to be the genetic contribution to arthritis risk. His pioneering work comparing the occurrence of arthritis in the co-twin of affected identical and non- identical twins was a landmark in this respect. It was this work that Lawrence chose to highlight in his 1969 Heberden Oration, entitled "Rheumatoid Arthritis: Nature or Nurture?" This annual lecture is probably the most prestigious award in UK rheumatology and the award to Lawrence, a man with no established academic title, was a mark of the respect in which he was held. His studies and reputation spread far outside the UK, and he trained many distinguished overseas investigators. His studies were enhanced by employing iden-tical methods to further compare the occurrence of arthritis in northern England, with that for example in Jamaica or in a native American Indian population.
In 1977 his famous monograph Rheumatism in Populations was published, encapsulating his lifetime's contribution. This volume is a treasure trove of tables, graphs and charts for the serious student. Never a best-seller and not always easy to follow, it remains a unique collection of data to be cherished and exploited.
Lawrence resigned from the Directorship of the Field Survey Unit in 1968 but continued with his studies almost until he died. He was a regular visitor to the unit, pulling out an X-ray or a patient record. He maintained contact with many of his study subjects, collecting further information over the years, and continued to submit scientific communications of his findings. His brand of "shoe leather" epidemiology, with the investigator knocking on doors and painstakingly collecting his own data, has been supplanted by postal questionnaires, telephone interviews and clinic visits to a research nurse. His duplicated survey sheets have been superseded by computer-generated data capture forms appropriate for optical scanning, and his hand-calculated simple tabulations replaced by complex statistical models. Despite this Lawrence's work has survived and is still regularly quoted, an achievement in an era where results can be out of date even within a year.
Sadly in his latter years, Lawrence developed Parkinsonism that caused increasingly serious incapacity. His regular attendances up to two to three years ago at the convivial biannual North West Rheumatology Club ceased and his contribution was missed. He was cared for in his latter years by his second wife Ingle, who also supported his continuing scientific activities. He was a quiet gentle man most at ease reading a pile of X- rays or interpreting some columns of figures. The results of his labours will continue to inform those seriously interested in the discipline well into the next century.
John Stewart Lawrence, epidemiologist: born Brechin, Tayside 5 May 1908; married 1933 Ethel Clarke (two daughters; marriage dissolved), 1973 Ingle Wright; died Eccles 6 May 1996.Reuse content