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Reviews and Notes: Immunology and Rheumatology: Arthritis and Allied Conditions: A Textbook of Rheumatology

Arthritis and Allied Conditions: A Textbook of Rheumatology Twelfth edition. Volumes 1 and 2. Daniel J. McCarty and William J. Koopman; eds. 2151 pages. Philadelphia: Lea & Febiger; 1993. $198.50. American health care and internal medicine are undergoing a great transition with the evolving predominance of ambulatory services and managed care. In some ways this challenge is an opportunity for the internist to broaden the scope of his or her practice. Because occupational, sports-related, degenerative, and inflammatory musculoskeletal diseases are frequently seen in the clinic, rheumatology (broadly defined) is a major portion of adult ambulatory medicine. Thus, a text such as Arthritis and Allied Conditions should be relevant to more than a specialist within this small discipline. For the internist in any field, reading a clinically correlated update in immunology is the minimal cost of admission to understanding the impending manipulation of T-cell immunogenetics, cytokines, and cell adhesion molecules in clinical practice. The new edition of this book is successful in consolidating and integrating chapters on these basic elements of the immune system and has expanded coverage of fundamental mechanisms of disease in all areas of classic rheumatology. Within Arthritis and Allied Conditions lies a comprehensive textbook of rheumatoid arthritis. It contains superb chapters on all aspects of the rheumatoid synovium and broad coverage of clinical features and management. However, more emphasis is needed on teaching how to measure clinical outcomes; for example, a critical rheumatic review of systems, examination of specific joints, or specific instruction for prescription of exercise, splints, and orthotics would have been helpful. But the subsection on slow-acting antirheumatic drugs is detailed and would adequately guide the inexperienced physician in administering these useful but troublesome drugs. In many ways the chapters on connective tissue disease are the best in the text. The basic science chapters are clear in their relevance to the observed disease. Clinical coverage of myositis and lupus nephritis have been markedly improved from the previous edition. The chapter on systemic lupus by Dr. Rothfield has the tone of a professor's rounds: a dialogue in which clinical features, practical differentials, and management pitfalls are painted in broad strokes but with sufficient detail to be useful at the bedside. More chapters written in this style are needed. If this edition falls short, it is not because of lack of depth or content. Rather, because of groupings of topics, access to discussions of approach to common presenting problems (such as monoarthritis or rash with fever) is more cumbersome than that in competing textbooks by Katz or Kelly. Although independent chapters on fibromyalgia, back pain, and nerve entrapment syndromes discuss many of the major issues of occupational medicine, an editorial focus is not apparent in this area. A similar argument could be made in the treatment of athletic injuries. So, although this is a usable and familiar companion for the rheumatologist, further evolution will enable it to be an even more effective source of information for the primary care internist.