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FOREWORD TO THE FIRST EDITION

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Making and acting upon a decision are the critical events in any patientphysician encounter, although it is uncommon for either the patient or the physician to recognize the significance of this sequence. As the physician s experience with the problem at hand increases , the decisions and consequent actions often become more and more instinctual. In the early days of aviation, pilots, distrusting their primitive and frequently failing instruments, were said to have flown by the seat of the pants; so, too, may the physician go with the feel of the situation. This manual is built on facts. It describes the acquisition of needed facts from the physicianpatient encounter in rheumatic disease, the integration of those data into a decision, and the action that logically results from that decision. It constitutes not only a reasonable substitute for experience for the younger physician but also an excellent yardstick against which the older can measure performance.

There was a time not long ago when the patient with rheumatoid arthritis was viewed as a collection of inflamed joints. The very concept of the disease as a systemic affliction, developed by clinicians of yesteryear such as Bauer, Ragan, Copeman, and Hench, was critical to the development of rheumatology as a discipline of internal medicine, while placing perhaps undue emphasis on systemic features. These pages help to restore the concepts that all that hurts is not systemic disease, that articular symptoms are the major feature of rheumatoid arthritis, and that those who would deal with disease manifesting as musculoskeletal pain must also be aware of local afflictions such as march fracture, tennis elbow , and slipped capital femoral epiphysis. These pages represent the happy juxtaposition of the medical and orthopedic surgical expertise of the Hospital for Special Surgery, a hospital with an enviable tradition of cooperation and of excellence in both disciplines.

The pearls are numerous and genuine , and yet no one will consider this manual all-encompassing. It would not be easy to compress a more practical and useful clinical introduction into fewer pages. The reader will use it as such: a personal introduction to the complex and fascinating pathophysiology of human locomotor disease.

John L. Decker, M.D.
National Institutes of Health
Bethesda, Maryland