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Explore This IssueMarch 2014
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In 1770, Dr. Ezekiel Hersey, a wealthy physician practicing in Hingham, Mass., bequeathed £1,000 to Harvard College for the support of a Professor of Anatomy and Physic. This would become the university’s first endowed chair in the medical sciences. However, it was 12 years before Harvard acted on Hersey’s bequest to establish a professorship and build a medical school. This delay was due to the insufficient funding of the initial endowment and the monetary inflation created by the American Revolutionary War, which eroded Harvard’s finances. Eventually, other Hersey family members pledged support, and the professorship was established. More than two centuries later, this august epithet continues to be bestowed upon the incumbent physician-in-chief at my hospital. How quaint! I find this title amusing, befitting an alchemist or anatomist, but not a physician scientist. After all, the term physic conjures up images of William Shakespeare’s King Lear, reciting: “Take physic, pomp. Expose thyself to feel what wretches feel.” Even the venerable Oxford English Dictionary considers physic, whose origins date to the late Middle English era, nearly obsolete. Yet in the rarified halls of academia, where tradition trumps the trendy, physic lives on.
For many years, the ACR had taken a similar line of reasoning with its use of the antediluvian term, rheumatism. Since its inception in 1958, our flagship publication, Arthritis & Rheumatism (A&R), had sported this word on its masthead. Over the centuries, physicians and patients alike have used it to characterize an exceedingly vague array of aches and pains. Unlike beauty, rheumatism is not in the eye of the beholder. Is it a serious ache or a transient pain of little consequence? Though the lack of any corresponding physical signs should have, in theory, limited its utility in clinical practice, this was hardly the case. To paraphrase Macbeth, rheumatism is a word full of sound and fury, signifying nothing.
I once saw a patient who, on the advice of his general practitioner in London, had been told to consume several grams of aspirin daily to treat his rheumatism. Years later, following his first leg amputation, his medical team wanted some insight as to why the arteries in his amputated extremity showed the classical histopathologic features of giant cell arteritis.1 A few months later, he lost his other leg to the same disease. Were his longstanding complaints of rheumatism obscuring an undetected case of polymyalgia rheumatica (PMR)? Would timely corticosteroid therapy to treat PMR have prevented this tragic outcome? As is often the case, rendering a diagnosis of rheumatism enables the practitioner to falsely claim insight and knowledge about a condition, to briefly commiserate with the patient, and then to shoo them away. This approach may be only marginally better than Sir William Osler’s advice for physicians to exit through the back door when an arthritic patient enters through the front door.
Rheum: An Evolution
An obvious problem facing rheumatology has been the lack of having an identifiable organ system that we could all rally around. The multisystem diseases that we manage can be fairly untidy, straying into many organs and tissues, requiring rheumatologists to be skilled in a variety of disciplines. In contrast, other specialists can limit their range of interest. For example, neurologists can focus all of their attention on the nervous system, cardiologists can keep their trained eyes on the beating heart and its attendant plumbing, and gastroenterologists can stay busy probing the various abdominal viscera.