Primer on the Rheumatic Diseases

In 1934, a 52-page pamphlet under this same name introduced rheumatology to US physicians. It was a modest effort, but for a new discipline in internal medicine, it was a beginning. Rehabilitation was in its infancy, beds were occupied for lengthy periods by patients who had rheumatoid arthritis, and Forrestier's discovery of the efficacy of gold salts was still to come and would be opposed by Russell Cecil because Forrestier thought he was treating tuberculosis. Even 20 years later, not much had changed. Hans Wayne could still write an article in Archives of Internal Medicine advocating 10.8 g of aspirin as treatment of rheumatoid arthritis, osteoarthritis was still considered to be predominantly a degenerative disease, and fibromyalgia was still termed fibrositis. Arthritis surgery consisted chiefly of osteotomies. This latest edition of the Primer testifies to how far the field has come since then.

Despite its title, the Primer really is a textbook that discusses evaluation and treatment, much of it new since the 12th edition. Except for surgery, patients are no longer hospitalized or, if so, only for brief stays. The inpatient arthritis centers are a relic of the past. The editors are new, as are many of the authors. Rheumatic fever has become a rarity, at least in the Western world. Many chapters discuss disorders that were unknown 75 years ago. In fact, the Primer has become a textbook.

I suspect that much of it is too detailed for the general clinician who wants clues as to what to diagnose and what to do. But with some effort the answers are there, and referral to a specialist is rarely needed or necessary. Although the writing is at times pedestrian, and too many sentences are in the passive mode, they still provide the basic outline for assessment and treatment. Regrettably, fibromyalgia still gets a chapter and a mention in other chapters, though it is part of the chronic pain spectrum and neither fibrous tissue nor muscles seem to be involved. Clauw and Dadabhoy give a measured description of this syndrome, whose naming remains controversial.

An international array of experts constitutes the primary list of contributing authors. The soft-cover book leads off with Patience White and Rowland Chang discussing public health and arthritis. They emphasize that the gamut of disorders are foremost in the complaints of patients, whether they present with these disorders as sole symptoms or part of a cacophony of distress. A section on evaluation follows, and a reasonable discussion of musculoskeletal signs and symptoms is attempted.

The molecular and cellular basis of immunity is broached and remains all-important in understanding most of the diseases. Individual diseases (syndromes?) are covered in the next 29 chapters. These chapters are as up-to-date as the latest journals. Rehabilitation, psychosocial factors, and self-management strategies are insightfully detailed. Whereas pain may be the chief reason patients become patients, adequate management protocols and regimens are importantly elaborated and stressed.

All the current treatments fill the remaining chapters, including complementary and alternative therapies, and the appendices feature criteria and guidelines. Any physician who reads the book may feel no need for specialist referral, but rheumatologists will, in fact, feel more confident and assured as they offer their diagnoses and recommend treatment options. As Shakespeare noted, the rheumatic diseases do abound; these rheumatic diseases and the pain and disability they cause still remain the chief reasons for medical consultation.