Proceedings of the Annual Meeting of the American Rheumatism Association. June 1516 1967 New York N. Y. Abstracts of Papers Submittedкод для вставкиСкачать
AMERICAN RHEUMATISM ASSOCIATION A Section of the Arthritis Foundation 1212 Avenue of the Americas, New York, N. Y. 10036 President: DONALD F. HILL, M.D., 2430 EAST 6 T H STREET, TUCSON, ARIZONA 85719 First Vice President and President Elect: EVANCALKINS,M.D., 100 HIGH STREET, BUFFALO, Second Vice President: LEONSOKOLOFF, M.D., N.I.A.M.D., BLDG. 10, RM. N. Y. 14203 3~114,BETHESDA, MARYLAND 20014 Secretary-Treasurer: CHARLES M. PLOTZ,M.D., 125 EAST 73 STREET, NEW YORK, N. Y. 10021 0 Executive Secretary: MARGARET M. WALSH,1212 AVENUE OF THE AMERICAS, NEW YO=, N. Y. 10036. Proceedings of the Annual Meeting of the American Rheumatism Association June 15-16, 1967 New York, N. Y. Abstracts of Papers Submitted EDITOR: Stanley L. Wallace SCINTILLATION SCANNING O F JOINTS WITH TECHNETIUhl-99-”1 Donato Ahrcon-Segovia, Miguel Trujeque, Enrique Tocar and Marco Antonio Adame, Mexico City, Mexico Isotopic scanning of joints within 3 hours of intravenous administration of Technetium-99 (99MTc) shows higher uptake by joints affected by inflammatory processes than by normal or degenerated joints. In some instances it has afforded differentiation between periarticular and intraarticular inflammation and in others it has shown a higher uptake in painful joints without clinically detectable inflammation. Advantages of 99MTc over other isotopes are its short half-life, its pure gamma emission, its rapid distribution, the lack of need of thyroid suppression, the absence of allergic reactions and the minimal radiation exposure. Joint scans with this isotope have nitid images that facilitate interpretation. Scintillation counts over the knees done at 5 minute intervals after 99MTc injection in 2 patients with unilateral knee involvement (1 gout, 1 rheumatoid arthritis) and in 2 normal volunteers showed that, although all curves were similar, reaching a plateau within 15 minutes and later decreasing slowly, radioactivity counts were up to 55 per cent higher in affected knees. Autoradiography in one and scintillation counts in both synovial biopsies done within 30 minutes of intravenous administration of 99MTc in 2 patients with chronic synovitis showed no significant uptake by the synovial membrane. Synovial fluid showed moderate radioactivity. Increased uptake of 99MTc by joints affected by inflammatory processes seems to be due to an increase in soft tissue volume and its blood supply, and to joint effusion when present. The clinical application of isotopic scanning of joints with 9 9 M T c will be illustrated and discussed. 262 263 ABSTRACTS RHEUMATOID FACTOR I N ANKYLOSING SPONDYLITIS Clemente A. Amante and John J . Calabro, Jersey City, N. J. Rheumatoid factor ( R F ) is rarely reported in ankylosing spondylitis (AS). Yet, of 30 AS patients carefully observed for almost 9 years, a positive latex fixation (titer of 1:80 or greater) has been noted in 9 patients at some time during the observation period. The highest median titer was 1:1,280. The range was 1:320 to 1:5,120. The mean duration of titer was 27 months with a range of 10 to 44 months. Appearance of RF was transient; the incidence at any given point of time for the group as a whole was not more than 10 per cent. Of 9 seropositive patients, 2 have ulcerative colitis, 2 regional enteritis, 8 active peripheral joint involvement, and 2 vascular complications. Two AS patients with ulcerative colitis and low titers of RF initially developed high titers transiently with vascular complications. Vasculitis occurred in 1 patient and an infected ankle AND ulceration in the other. Of 21 seronegative patients, 1 has ulcerative colitis, 5 active peripheral joints and none with vascular complications. There was no difference between seropositive and seronegative patients as to age of patients, age of onset, modes of onset, duration of AS, presence of aortic insufficiency or iritis, cerebrospinal fluid protein, X-ray changes or ARA functional class and anatomic stage. Of 30 control patients with ulcerative colitis and regional enteritis without AS, only 3 had RF. These preliminary observations demonstrate that rheumatoid factor may occur in the course of ankylosing spondylitis. It is suggested that evolution of rheumatoid factor occurs among patients with active peripheral joint involvement, vascular complications and underlying gastrointestinal disorders. INCORPORATION OF P O 4 A COMPARISONOF THE SIMULTANEOUS PRO-c14 INTO BONEMATRIXO F NORMAL AND DENERVATED RAT LIMBS Thomas G. Argyros and Marwell Schubert, New York, N. The formation of the 2 major components of bone matrix, collagen and chondroitin sulfate, was studied quantitatively and simultaneously in rabbits and rats by injection of 9 5 0 , and proline-Cl4. The animals were sacrificed 24 hours later; the shafts of long bones were decalcified in a formalincitrate solution. The hydrolyzed samples of bone matrix were analyzed chemically for hexosamine and hydroxyproline, and by radiocounting techniques for S3504 and hydroxyproline-C14. The specific activity of hydroxyproline served as a measure of collagen formation; 9 5 0 , CPM, of chondroitin sulfate. EVALUATION OF A Y. Synchronous formation of collagen and chondroitin sulfate was demonstrated in normal rabbit and rat bone. Radioactive “hot and cold” areas in bone were also demonstrated. Unilateral osteoporosis was produced in the left hind limb of rats by sectioning of the femoral, sciatic and obturator nerves. Ten to 26 weeks after denervation the rats were injected with labeled sulfate and proline. There was an increased formation of labeled collagen and chondroitin sulfate in the denervated limb as compared to the intact right hind limb. SEMI-QUANTITATNE B E T A ~ J B E TCOMPLEMENT A~~ ASSAY Joseph P . Bailey, The participation of complement in several disease states, and specifically in the glomerulonephritis of systemic lupus erythematosus, has led to a search for complement assay lending itself to the clinical laboratory. Betalc/Betala globulins are part of the third component of complement, involved after C‘l, C‘4 and C’2. There has been published evidence that changes in concentration of these globulins reflect change in total complement activity (Pediatrics 35:765, 1965). Micro-Ouchterlony plates were prepared and undiluted and JT., Augusta, Ga. serial two-fold dilutions of serum, ranging from 1:2 to 1:32, were placed in the 6 outer wells and observed for precipitin lines against commercially available goat anti-human Beta l,/Beta l a globulin in the center well. Normal sera consistently formed precipitin lines at dilutions of 1:32. Sera from patients with active systemic lupus erythematosus with and without nephritis consistently had titers of less than 1:32 (usually 1:8 or less) indicating decreased Betalc/Betala concentration. Corticosteriod therapy has resulted in 264 ABSTRACTS return to normal titers in patients who improved clinically. Variations in Betalc/Betal, levels have been a useful guide to effectiveness of therapy. Synovial fluids from rheumatoid arthritis patients have consistently demonstrated decreased Beta,J Betal, concentrations compared to levels in serum. EFFECTOF AGINGON We think this test provides a simple, easily performed, semi-quantitative measurement of complement activity in serum and synovial fluid which, because of the ease of determination, can greatly increase the clinical usefulness of this test. VISCOELASTIC AND CHEMICAL PROPERTIES HUMANSYNO\’IAL FLUID THE OF E . A. Balazs, P. 0. Seppala, D. A. Gibbs, I. F. Duff and E. W . Merrill, Boston and Cambridge, Mass. and Ann Arbor, Mich. Viscoelastic measurements and chemical determinations were carried out on synovial fluids obtained from the knee joints of normal male young and old donors and on fluids from osteoarthritic patients. The concentration of hyaluronic acid and proteins, the total amount of hyaluronic acid per joint, and its limiting viscosity number were essentially the same in fluids taken from young and old normal donors. I n osteoarthritic fluids the hyaluronic acid concentration and Limiting viscosity number were lower than in normal fluids, while the total amount of hyaluronic acid and the protein concentration were higher. Generally, fluids from normal young and old persons exhibited comparable values for the shear storage modulus G’ and the shear loss modulus G” measured at low strain frequencies. The most significant difference between these normal fluids was in the G”/G ratio obtained at high strain frequencies. This ratio was much smaller for fluids from young donors compared to that from old donors. Thus at high strain frequencies, the synovial fluid behaved like an elastic material in young persons, while in old persons at the same strain frequencies the synovial fluid showed a much less elastic quality. This suggests that the rheological quality of the hyaluronic acid in the synovial fluid has changed with aging. This change is not in the apparent molecular weight or in the concentration of hyaluronic molecules, but is a much more subtle physicochemical change, which may relate to the interaction between the hyaluronic acid and the other molecules in the synovial fluid. The G‘ and G” values in the fluids from osteoarthritic patients were considerably lower than in normal fluids. These low values were a consequence of the lower concentration of hyaluronic acid and its lower limiting viscosity number. LOCALIZATION O F HYALURONATE-H3 SYNTHESIS IN SYNOVIAL CELLS Peter Barland, Carol Smith and David Hameman, New York, N. Y. Synovial membrane cells in tissue culture have long been known to synthesize hyaluronate and to secrete it into the medium. The intracellular sites of hyaluronate synthesis and storage are unknown. We have studied this problem using high resolution autoradiography of cell cultures derived from normal and rheumatoid synovial cells. Glucosamine was found to be a specific precursor for the hyaluronate these cells produce. Monolayers of synovial cells were incubated in medium containing glucosamine-6-H3. The medium was dialyzed, and the remaining radioactivity was shown to be in hyaluronate; over 80 per cent of the counts were rendered dialyzable by testicular hyaluronidase digestion. The hyaluronate-H3 was isolated from the medium by zone electrophoresis. Acid hydrolysis and paper chromatography showed counts confined to glucosamine. Cell cultures incubated with glucosamine-6-H3 for varying times were processed for electron microscopic autoradiography. By coating thin sections of the cells with a photographic emulsion sensitive to the radioactive emission from tritium ( H 3 ) , it is possible to visualize, as silver grains, the labeled material within the cells. Grains were localized to the vesicles of the Golgi apparatus, and to large clear vacuoles occasionally merging with the cell membrane. Grains were not noted in the rough endoplasmic reticulum, the nucleus, mitochondria or the prominent dense granules, residual bodies and lipid vacuoles found in these cells. The presence of the radioactivity in the hyaluronate in these cells was established by successive extractions with alcohol and acid. Paper chromatography of an HC1 extract showed counts in glucosamine. These studies show that the Golgi apparatus of these synovial cells plays an important role in the cellular synthesis and secretion of hyaluronate. 265 ABSTRACTS SEPTICARTHRITIS DUETO PASTEURELLA MULTOCIDA COMPLICATING RHEUMATOID ARTHRITIS W . F. Barth, L. A. Healey and 1. L. Decker, Bethesda, Md. and Seattle, Wash. Two patients with chronic active rheumatoid arthritis on adrenocorticosteroid therapy developed septic arthritis of the knee joint from which Pasteurella multocida was the sole organism recovered. In both cases the initial lesion was an ulceration near the malleolus following a cat scratch. Cellulitis subsequently developed involving the entire lower extremity with extension anteriorly to involve the knee joints in both cases. In spite of in vitro sensitivity to the antibiotic prescribed, prolonged therapy was required before complete resolution occurred. P . multocida, while recognized as a cause of human septic arthritis and osteomyelitis, has not been reported in conjunction with rheumatoid arthritis. The organism is common in the oropharnyx of healthy dogs and cats and was found in one of the pets involved in these cases. Treatment of the cat did not eliminate the organism. Infection in man by this organism commonly follows dog or cat bite or cat scratch and is probably more frequent than currently appreciated. In culture the organism is readily confused with hemophilus, neisseria, or proteus unless the source of the culture is specified. A short course of antibiotics often eradicates the initial infection in normal individuals, but such treatment did not eliminate the infection nor prevent joint involvement in our cases. Since the carrier rate in dogs and cats is high, they should be regarded as a significant environmental hazard, particularly for the patient with rheumatoid arthritis or other forms of chronic synovitis. PLACEBO RESPONSIVENESS-INFLUENCE OF PREVIOUS THERAPY Robert C . Buttemnun and William R. Lower, Berkeley, Calif. It has been demonstrated (J. New Drugs 6: 137, 1966) that analgesia attained for musculoskeletal disorders persists for days or weeks after cessation of drug trial. A further review of 173 patients who received placebo therapy for 230 trials indicates that responsiveness is dependent upon effectiveness of previous therapy, diagnosis, sex and race. Placebo, as an initial trial (71 patients), was effective for satisfactory analgesia, regardless of musculoskeletal condition, in 28.1 per cent. If placebo therapy followed an ineffective drug trial (45 patients) analgesia was obtained in 17.7 per cent. Following an effective drug trial, placebo therapy was still responsive at one week (103 patients) for 66.0 per cent, 2 weeks (107 patients) for 52.3 per cent, and 3 weeks (111 patients) for 43.2 per cent. In most categories osteoarthritic patients were more responsive to placebo therapy. Rheumatoid patients noted a poor response to placeboes, for an initial trial (15.9 per cent), and after an ineffective trial (0.0 per cent), but continued to respond to a placebo following an effective drug trial (54.5 per cent) for the first wek, and with more rapid loss of effectiveness, 36.3 per cent by the second week and 26.1 per cent for the third week. Negro patients were more responsive to placebo therapy following an effective drug trial than Caucasian patients. Since the interaction of drug trials is highly significant ( p <0.001), classical crossover evaluation of analgesic and antirheumatic agents requires modification. ANTIGEN HYPOREACTIVITY TO AN EXOGENOUS IN SYSTEMIC LUPUSERYTHEMATOSUS ( SLE ) John Buum, Dallas, Tex. Systemic lupus erythematosus (SLE) is often considered a disease of immunological hyperreactivity. A number of studies in which patients with SLE have been immunized appear to support this concept. The responsiveness of patients with SLE to an exogenous antigen has been studied by immunization with a dose (0.1 ml.) of brucella antigen (2,OOOX 10 6 killed bacteria per ml. ) sufficient to produce a measurable response in all of 18 normal female subjects (av. age 19). Twenty-three female patients with SLE (av. age 34) were similarly immunized. At immunization, the average dose of prednisone was 10 mg. (range 0-25 mg.); 7 received no steroid. Agglutination titers were measured at 1, 4 and 12 weeks. All sera showing activity were subjected to sucrose gradient ultra. centrifugation to determine the distribution of IgG and IgM antibody activity. The geometric mean titers at 1, 4, and 12 weeks in the normals were 285, 233, and 179 respectively, while in SLE they were 34, 45, and 47. 266 ABSTRACXS IgC and IgM antibody activity showed parallel reductions in the SLE group. These results indicate that patients with SLE were hyporeactive to stimulation with an exogenous bacterial antigen when compared to normal controls. Since the amount of prednisone administered was not in the immunosuppressive range, and there was no difference in antibody response between patients on or off prednisone at the time of immunization, it may be assumed that this agent did not play a role in the diminished response. The observed hyporeactivity to an exogenous bacterial antigen in SLE may be in accord with the apparent decreased resistance to infection commonly observed in patients with SLE. CORRELATION BETWEENTHE RHEUMATOID BIOLOGICALLY ACTIVEFACTOR ( RBAF ) AND CLINICAL FEATURES OF RHEUMATOID ARTHRITIS(RA) D . A. Bell, D. A. Gordon, R. Baumal and I . Broder, Toronto, Canada We previously described a factor (RBAF) found in RA serum and synovial fluid, which had the properties of a soluble antigen-antibody complex (Arthritis Rheum. 8:433,1965). This factor was not found in healthy persons or in forms of arthritis other than RA. I t sedimented with the serum macroglobulins but was specifically precipitated by anti-human IgG. The RBAF showed the capacity to stimulate histamine release and was assayed on the basis of this property. We have been conducting a prospective study to determine whether the RBAF occurs systematically or at random in persons with RA. The present report describes the data obtained at the time of the initial examinations in this study. The mean duration of disease was equal in persons who were RBAF-negative as compared with those demonstrating the RBAF in serum and/or synovial fluid. However, the RBAF positive group had greater evidence of articular destructive changes, both clinically and radiologically; other evidence of increased disease activity in this group was indicated by the presence of more pronounced constitutional symptoms, a higher Lansbury index, an increased frequency of synovial effusions, and a greater prevalence of nodules, splenomegaly and other extra-articular manifestations of rheumatoid disease. AIthough these findings suggested that the RBAF was related to the level of disease activity in RA, they did not clarify the sequence of this relationship. DIAGNOSIS OF EARLYARTHRITIS AND OUTPATIENTS) ( A 1-8 YEAR FOLLOW-UPSTUDYOF INPATIENTS Sidney S. Berkowitz, Edwmdo Guariglia, Samuel Laurian, and Otto Steinbrocker, New York, N. Y. Sixty-eight patients whose original diagnoses were acute or initial arthritis were reexamined 1 to 7 years later. The diagnoses were confinned in 33 (48.5per cent) and had to be revised in 11 (16.2 per cent) patients. The origin of the arthritis could not be determined in 7 other patients, and there no longer was evidence of arthritis in the remaining 18 patients. Thirteen of the latter were probably instances of rheumatic fever that were no longer active. Fifty-five outpatients whose original diagnoses were possible or probable rheumatoid arthritis, based on the criteria of the American Rheumatism Association, were reexamined 3-8 years later. Approximately 1/3 of the patients originally diag- nosed as possible rheumatoid arthritis and 36 of those diagnosed as probable rheumatoid arthritis eventually progressed to definite rheumatoid disease. Twenty-seven per cent were found to have musculoskeIeta1 diseases other than rheumatoid arthritis, and 22 per cent on reexamination showed no evidence of any musculoskeletal disease. These findings emphasize that clinical and laboratory diagnostic features are often inadequate to make a reliable diagnosis in early or acute arthritis. The “test of time” frequently is needed to arrive at a final diagnosis. Care should be exercised in the use of potent drugs until a definite diagnosis is established. AS THE PRINCIPAL AORTICINSUFFICIENCY OF SYSTEMIC LUPUSERYTHEMATOSUS MANIFESTATION G. C. Bernhard, R. L. Lung and G. T . Hensley, Milwaukee, Wisc. Aortic insufficiency is uncommon in systemic lupus erythematosus (SLE ) and has not been de- scribed as the presenting or principal manifestation of this disease. 267 ABSTRACTS Three patients are reported with this clinical problem. Two women had intractable congestive heart failure, auscultatory, hemodynamic and cinema-angiocardiographic evidence of severe aortic regurgitation. Other features of SLE included non-deforming arthritis, fever, skin rash, nephrotic syndrome, hyperglobulinemia, and either positive LE phenomenon or antinuclear factor. Multiple blood cultures were negative. Postmortem examination showed pericarditis and myocarditis with fibrinoid necrosis. There was aortic valve dilatation. Aortic valves were incompetent due to dilatation of the aortic ring, and the valves were markedly thinned with central perforations and areas of fibrinoid necrosis, There were no verrucae and no features of bacterial endocarditis. The kidneys showed evidence of lupus nephritis, and there was periarteriolar fibro- sis in the spleen. The third patient is a 59-yearold man who had arthralgias, autohemolytic anemia, hypergammaglobulinemia and LE phenomenon. H e developed clinical features of aortic incompetence and recurrent congestive heart failure. Several blood cultures have been negative, and he has been afebrile. Marked valve leaflet thinning and fenestrations seen in the autopsy cases occurred after corticosteroid therapy. While the role of corticosteroids should be considered in the production of the aortic valve changes, it is difficult to implicate this medication since one of the autopsied patients had been on corticosteroids only during the last month of her life. The primary reason for this report is to point out that SLE should be added to the list of causes of severe and progressive aortic insufficiency. “AMYOPATHIC” DERMATOMYOS~TIS Yale B. Bickel, Lauren Reager, J . B. Peter and Carl M . Pearson, Los Angeles, Calif. Polymyositis is a pleomorphic syndrome characterized by diffuse inflammatory and degenerative involvement of skeletal muscle, often associated with varying dermal and systemic features. The term dermatomyositis describes a syndrome wherein dermal and myopathic involvement coexist. Ten patients were encountered in whom muscle disease was minimal or absent, despite the presence of rash indistinguishable from dermatomyositis. The group consisted of 8 women and 2 men, ranging in age from 3 to 65 years. Evidence of muscle weakness was absent in 4, minimal in 3, and moderate, but rapidly regressed, in 3 cases. EMG was normal in 6 cases, and revealed fibrillation potentials in 3, 2 of whom h i d moderate weakness. Muscle enzymes were normal in 7 and only transiently elevated in 3 cases, Muscle biopsies from 5 patients were normal or minimally abnormal and none were diagnostic of myositis. Time from onset to diagnosis, in months, varied from 1.5 to 12, with a mean of 6.5. Associated conditions included rheumatoid arthritis, salmonella enteritis, pulmonary “fibrosis”, thyroid disease, pregnancy and invasive epidermoid carcinoma of the cervix. Skin biopsies obtained in 7 of 10 patients revealed varying degrees of hyperkeratosis, follicular plugging, edema of dermal collagen, and perivascular inflammation. Necrotizing angiitis and basal cell degeneration were absent. These data suggest that dermatomyositis represents a disease spectrum wherein muscle and dermal features may coexist to varying degrees. Polymyositis may occur without skin involvement, and the dermal features may be seen in the absence of detectable muscle disease. “Amyopathic” dermatomyositis represents another variant in the clinical spectrum of myositis. FUNCTION AND INTERMITTENT STEROID THERAPY ADRENOCORTICAL IN RHEUMATOID ARTHRITIS Paul J . Bilka, Minneapolis, Minn. Adrenocortical function was studied through the use of the oral metyrapone (“metopirone”) test in 15 patients who had been on no ( 2 patients) or various cortisol derivatives (13 patients) and were then placed on a single cortisol derivative-dexamethasone. All patients had at least a %month trial of dexamethasone given every other day, and 11 patients had a t least a 2month trial of dexamethasone given two times a day. Nine patients were further studied after a change to prednisone or prednisolone given once a day or every other day for about 3 months; 6 of these patients were still further studied after an additional 10 to 12 months of their intermittent schedule. Dexamethasone, a long-acting steroid analog, failed to improve 17-hydroxy-corticosteroid excretion despite the alternate day dosage administration in 13 of the 15 patients, and actually caused suppression in 6 of these patients. Still 268 ABsTRAms greater suppression, however, was evident with the twice a day dexamethasone dosage. When 9 patients were changed to the shortacting steroids, prednisone or prednisolone, given every other day or a once a day (AM), 17OHCS excretion improved in 6 and was unchanged in 3 patients after an average of 3 months therapy. And when 6 of these 9 patients were continued on this same intermittent schedule for an additional 10 to 12 months, 17-OHCS excretion improved or remained unchanged in 5 and showed a modest fall in only one patient. These data point to a definite preference for the use of the short acting adrenocorticosteroids every AM or every other day as a means of minimizing adrenocortical suppression, The clinical control of the patients’ symptoms was more difficult on intermittent steroid therapy, but most patients developed a tolerance to the initial “swings” in their arthritis symptoms, and in only one patient was it necessary to go back to the two-timesa-day dosage schedule in order to regain adequate symptomatic control. The data did not indicate significant differences in the clinical signs of steroid toxicity when patients were on the different dosage schedules. ANKYLOSING SPONDYLITIS WITHCHILDHOODONSET Samson Bitnun, Jane Schaller and Ralph J . Wedgwood, Nelson, British Columbia and Seattle, Wash. Ankylosing spondylitis is rarely recognized before puberty. We have seen 7 males with ankylosing spondylitis beginning between ages 7 and 12 years (current ages 15 to 38 years). Three presented with pain in low back, hip, or groin. Four presented with asymmetric peripheral arthritis (knees, ankles, feet, MCP); 3 of these developed low back symptoms within 4 years of disease onset. Six now have stiffness of the entire spine; 1 has stiffness limited to lumbar spine. Six have decreased chest expansion. All have bilateral sacroiliac destruction or fusion radiologically; 6 have radiologic findings consistent with ankylosing spondylitis in lumbar spine, and 4 in thoracic or cervical spine. Four have destructive hip disease; only 2 have had persistent peripheral arthritis with radiologic changes. None has had bowel disease, urethritis, psoriasis, rheumatoid nodules, rheumatoid factor, or iritis. Three have had low-grade fevers; 3, growth retardation; 3, duodenal ulcers; and 5, consistly elevated sedimentation rates. Function has remained good in 5, but is poor in 2. Although 6 of these patients had early symptoms referable to the low back, only 2 were recognized as having ankylosing spondylitis during childhood (other diagnoses: juvenile rheumatoid arthritis, acute rheumatic fever, pelvic chondrodysplasia ) . Ankylosing spondylitis should be considered in the differential diagnosis of childhood arthritis, particularly in children with low back, hip, or groin pain. This disease is to be distinguished from juvenile rheumatoid arthritis which predominantly involves peripheral joints and frequently involves the cervical spine, but almost uniformly spares the lumbodorsal spine and is associated with radiologic sacroiliitis without prominent low-back symptoms. HEMIARTHRITIS HEMIPLEGIAAND RHEUMATOID John H . Bland and Winston M . Eddy, Burlington, Vt. Hemiplegia protects against both rheumatoid arthritis and osteoarthritis on the paralyzed side. The mechanism is unknown. Both upper and lower motor neuron lesions confer protection. Clinical, radiologic and histologic evidence of hemiarthritis in hemiplegia has been described. Twelve cases supporting this general concept have been reported. The present report is of a patient with left ASEPTIC NECROSIS OF THE hemiparesis occurring in 1951, followed by development of severe rheumatoid arthritis within 4 months. The disease did not involve the paralyzed side, while gross destructive disease developed on the non-paralyzed side. The patient was observed over a 13-year period. Clinical and radiologic evidence of unilateral disease will be presented. Proposed protective mechanisms and their biologic importance are discussed. FEMORAL HEADS IN SICKLE A HEMOGLOBIN DISEASE Sheldon Blau and David Hamemnan, New York, N. Y. Heterozygous sickle cell disease (SA or sickle trait) is generally regarded as a benign disease, although a number of serious complications can occur, such as splenic infarcts, hyposthenuria, ABSTRACTS hematuria, and infarctions of other organs, all presumably secondary to vascular occlusions. Avascular necrosis of the femoral heads is a fairly well known occurrence in the homozygous variety (SS) of the disease, as well as in other heterozygous combinations of abnormal hemoglobins, but it is apparently rare in SA disease. The following apparently consititutes the third report in the American literature. The patient is a 43-year-old Negro laundry worker whose complaints were entirely confined to low back pain for several years. There were no previous illnesses. The only medication taken was Zactirin. Physical examination, including the gait, was normaI. Laboratory studies were normal except for hemoglobin electrophoresis, which revealed SA. X-rays of the hips were available from 1960. At that time only a lucent area in the left femoral head was observed. In 1961 there were multi-loculated defects in the right femoral head as well. In 1966 reactive sclerosis had filled in the lucent areas in both hips. Apparently, avascular necrosis of the femoral heads progressed without symptoms in this patient for many years. A review of possible predisposing factors other than SA disease was made, and none was thought to be contributory: trauma, alcoholism, ionizing radiation, Caisson disease, vascular insufficiency, systemic connective tissue disease, steroid therapy, and many others. Hemoglobin SA disease would seem to be the predisposing condition for aseptic necrosis of the femoral heads in this patient. THEINCIDENCE AND SIGNIFICANCE OF THE LUPUSERYTHEMATOSUS ( L E ) PHENOMENON IN 45 RHEUMATOID ARTHRITISPATIENTSOBSERVED FOR 10 YEARS Gilbert B. Bluhm, John W. Sigler, Dwight C . Ensign and John W. Rebuck, Detroit, Mich. This report summarizes the clinical findings and laboratory data of 45 patients with rheumatoid arthritis (RA) observed in a prospective study for a 1 0 year period. Fourteen of the 45 patients (31 per cent) exhibited LE cells. Three patients had 4 or more LE cells in a single test. One of these patients developed clinical signs of systemic lupus erythematosus (SLE) after 2 years of observation and is excluded from this summary. Nine patients have died. Histologic changes of SLE were absent in 4 patients autopsied. After 10 years, 32 patients remained available for clinical assessment. Twenty-two were in the LE cell negative (LEN ) group and 10 in the LE cell forming ( L E F ) group. None of the patients exhibited a positive serological test for syphilis. Nodules were present in 44 per cent, rheumatoid factor ( R F ) in 60 per cent, antinuclear factor (ANF) in 70 per cent, and 17 per cent exhibited Stage IV rheumatoid progression. All 11 patients in Functional Class 3 and 4 exhibited RF and 8 had subcutaneous nodules; whereas, of those patients in Functional Class l and 2, only 9 of 21 had R F and 6 of 21 had nodules. The average duration of disease was the same in both groups. Comparisons were made between the LEN and L E F patients. LEN (Median Disease Duration ) 16 Yrs.) LEF (Median Disease Duration) 17 Yrs.) ~- Stage I11 & IV Functional Class 3 & 4 RF Nodules Positive ANF 17/22 10/10 5/22 12/22 7/22 13/21 6/10 8/10 7/10 8/9 Our findings suggest that the transient occurrence of the LE cell in RA is associated frequently with progression to a more advanced stage of rheumatoid disease but infrequently with the development of SLE. THEPROCAINE AMIDE-INDUCED LUPUSERYTHEMATOSUS SYNDROME Stephen F. Bodman, Marvin J . Hoflman and John J. Condemi, Rochester, N. Y. Over a 6-month period, we have observed 13 cases of the procaine amide-induced lupus erythematosus syndrome. Our group includes 8 women and 5 men, all Caucasian. The mean age was 62 years. Symptoms began onIy after substantial amounts of the drug had been taken (mean total dose approx. 1 kg.; mean duration of therapy one and one-half years). Seven of 13 patients developed arthralgias and arthritis without x-ray changes, myalgias, pleurisy, pericarditis, fever, lymphadenopathy, hepatomegaly, splenomegaly, or weight loss. Six of 13 complained only of insidious malaise, weakness, anorexia, and mild musculoskeletal symptoms. ABSTRACTS Hematocrits were normal in 12/13. Leukopenia was found in 5/13 and absolute lymphopenia in 8/13. Renal function was normal. Five of 11 patients had positive non-gamma Coomb's test, indicating complement on the red cells. LE cell tests were positive in 12/13 patients. Antinuclear antibodies ( ANA ), determined by immunofluorescence and Hyland Lab latex nucleoprotein tests, were present in all 13 patients. High titers of IgG and lower titers of IgA and JgM ANA were noted by immunofluorescence. Two patients who were evaluated early in their illness were found to have negative LE cell tests and absent ANA but were found to develop positive tests later. Five of 13 patients had positive latex fixation ( antiglobulin) tests. Serum complement levels were within normal range. Hyperglobulinemia was present in 4/13, but the mean IgG value was at the upper extreme of the normal range. Five-month follow-up reveals that symptoms often persist for several months after drug cessation, requiring corticosteroids in 8/13 of our patients. ANA have disappeared from the sera of 3 patients. The non-gamma Coomb's test has become negative in all 5 patients. Latex fixation tests have become negative in 3/5 and have decreased in titer in 2/5. Significant decrease in IgG levels after drug cessation has occurred in all patients. RHEUMATOID ARTHRITIS, STEROID THERAPY, AND THE CRYPTOCOCCUS C. W. Brandt and E . C. Toone, Richmond, Va. The prolonged use of immunosuppressive agents, such as a corticosteroid, in a disease in which the immune mechanism is probably already deranged, such as rheumatoid arthritis, raises concern about potential infectious complications. Our attention has recently been diverted to the cryptococcus. A 56-year-old white man with advanced rheumatoid arthritis of 15 years duration, receiving 10 to 15 mg of prednisone daily, presented with the complaints of vertigo, headaches, weakness, and fever, and was found to have pyuria with azotemia (BUN 70 mg per cent). Initial urine cultures were negative for the routine pyogenic bacteria, hut cryptoccocus neoformanS was suspected in the urine sediment and confirmed by culture. Further studies, including needle biopsy of the kidney, demonstrated pyelonephritis with necrotising papillitis, and showed the cryptococcus in the renal parenchyma. Examination of the cerebrospinal fluid revealed the cryptococcus associated with pleocytosis, elevated proteins, and decreased sugar. Both the renal and central nervous system infections responded well to 1000 mg. of intravenous Amphotericin B, administered over 35 days. The records of the Medical College of Virginia Hospitals from 1956 to 1966 revealed a second case of steroid-treated rheumatoid arthritis complicated by cryptococcal infection, in this instance involving the lung and meninges. A third case of cryptococcal meningitis complicating corticosteroid treated rheumatoid arthritis was seen in another local hospital. Three cases of disseminated cryptococcosis occurring in steroid-treated rheumatoid arthritis serves to call attention to this as an infectious complication. Diagnosis may be difficult due to the variable clinical factors, often obscured by pre-existing disease. Alertness is demanded, however, since effective therapy is available. XANTHINEAND HYPOXANTHINE LEVELSDURING DRUGTHERAPY IN GOUT URINARY W. G. Briney, F . J . Baehnk, and B. A. Bartholomew, Denver, Colo. The use of the xanthine oxidase inhibitor, 4hydroxypyrazolo (3,4-d) pyrimidine ( HPP), in the treatment of gout results in increased levels of the urinary oxypurines, hypoxanthine and xanthine. The present study deals with urinary hypoxanthine and xanthine levels as determined in patients with gout during therapy with HPP, uricosuric agents, and anti-inflammatory agents alone and in combination. A paper chromatography method was used to separate xanthine and hypoxanthine. The individ- ual components were determined b y a coupled enzymatic reaction employing xanthine oxidase and uricase. Values for serum urate and 24-hour urinary uric acid, xanthine, and hypoxanthine levels will be presented. Single determinations on control patients (including 7 patients with renal transplants and three patients with untreated gout ) showed urinary xanthine and hypoxanthine levels from 1.5 to 32 and 2.0 to 28 mgm/24 hours respectively. Two patients evaluated on a metabolic ward for one-month periods had 1 ) in- 271 ABSTRACTS creased xanthine and hypoxanthine levels during HPP therapy, with the major rise in xanthine and 2 ) a relative decrease in both oxypurines when HPP and sulfinpyrazone were used concomitantly. Five patients studied weekly for 4 to 6 months showed prompt elevations of urinary oxypurines. The major rise was in xanthine in 4 patients and hypoxanthine in one patient. One patient receiving HPP showed a decrease in both oxypurines with the addition of indomethacin, and a return to pretreatment levels upon its discontinuation. These results, suggesting an individual variability in response to combination drug therapy in gout, will be discussed in detail. OCCURRENCE OF RHEUMATOID ARTHRITIS ( RA) AND RHEUMATOID FACTOR( R F ) IN LARGEFAMILIES T . A. Burch and P . H . Bennett, Phoenix, Ariz. I n previously reported studies no evidence was found to support the hypothesis that rheumatoid arthritis (RA) or rheumatoid factor ( R F ) in the Blackfeet and Pima Indians were determined by any presently demonstrable genetic mechanisms. These studies were based on epidemiological data from 1101 Blackfeet and 969 Pima Indians, aged 30 years and over, living on their respective reservations. Further analysis has shown that rheumatoid factor, detected by the bentonite flocculation test and the sheep cell agglutination test, occurred one and a half times as frequently among the larger sibships of the Pima tribe than among the smaller sibships. Rheumatoid arthritis, probable and definite, was found more than twice as frequently among the larger sibships of the same tribe (P<0.01). The relationship of RA to sibship size appeared to be independent of age, but that of RF was most marked when the eldest sibling was at least 55 years old. No definite evidence of an increased risk to the spouse of affected subjects was found. These data provide strong evidence that RA and RF are the result of environmental influences, perhaps infections, which probably operated during infancy, childhood or adolescence. The detailed findings will be presented. ABRUPTCHANGES IN TARGET ORGANENCOUNTERED AMONGPATIENTSWITH AUTOIMMUNE DISEASE E. M . Caperton, Jr., R. C . Williams, Jr., P . J. B i l k and M . J. Murray, Minneapolis, Minn. Some predictable pattern of clinical progression of the various so-called autoimmune diseases is well known. However, frequently a considerable degree of overlap of clinical or pathologic findings occurs. We have recently encountered 6 patients exhibiting evidence for abrupt transitions of involvement of multiple organ systems during their disease. These patients showed little in the way of concurrent overlap, but rather a clinical course that was marked by abrupt changes in the target organs involved. Included in this study were patients with: 1 ) Lupus erythematosus, manifested as polyarthritis. Complete remission followed 12 years of symptoms. Following a traumatic episode, patient developed classical ulcerative colitis. 2 ) Rheumatoid arthritis complicated by ulcerative colitis. Colectomy led to complete remission of gastrointestinal disease whille the rheumatoid arthritis progressed unabated. 3 ) Remission of multiple sclerosis followed by typical lupus erythematosus. Remission of the lupus was prompted by steroid therapy; symptoms of multiple sclerosis promptly returned. 4) Severe ulcerative colitis requiring colectomy for control. Six days later arthritis, which progressed to typical rheumatoid arthritis, ensued. 5 ) A patient showing evidence of multiple disease states, each appearing independently of the other. In order of appearance they were asthma, bloody diarrhea, lupoid hepatitis, thyrotoxicosis, nephrosis, skin ulceration, and terminally brain and pancreatic necrosis. 6 ) Chronic glomerulonephritis requiring kidney transplantation, followed by ulcerative colitis. The association of multiple concurrent organ involvement is a familiar clinical entity; however, abrupt transitions notable among these patients present unique situations. It is possible that target organ shift is secondary to exhaustion of the antigenic capacities of the original organ. 272 ABSTRACTS RHEUMATOID KNEE SOFTTISSUE STABILIZATION OF THE UNSTABLE Peter A. Casagrande, Buffalo, N. Y. The problem of the unstable, painful knee is a vexing one that occurs in 20 per cent of rheumatoid patients. In over 75 per cent of these knees, the instability is due to capsular-ligamentous laxity secondary to chronic hypertrophic synovitis. The laxity is most pronounced in the weight-bearing posture with the knee usually assuming a valgus deformity. How can the knee be stabilized? The method herein described produces adequate stability together with a functional range of motion. Our criteria for the selection of surgical candidates are two-fold: 1) the instability must be primarily due to capsular-ligamentous laxity, and 2 ) abduction (or varus) of the knee must exceed 30 degrees on stress (weight-bearing or passive manipulation). The surgical procedure consists of using 2 long strips of quadriceps fascia to re-enforce the cruciate and lateral ligaments (modified Jones procedure), in conjunction with a thorough joint debridement, i.e., synovectomy, partial patellectomy, and removal of osteophytes, deranged menisci and loose bodies. Post-operative care is most important. The leg cast is removed in 48 hours. Passive manipulations of the joint is then done on a sedated patient. A cylinder cast is applied which is bivalved the next day. Thereafter, passive and active joint motion including quadriceps muscle exercises is done two or three times daily. Isometric exercises are done every hour. Ninety degrees of flexion can be obtained in most knees within 7 to 14 days. Ambulation is permitted with crutches and the bivalved cylinder cast 3 to 4 days postdperatively. The cylinder halves are dispensed with as soon as the knee can be extended against moderate resistance. This soft tissue stabilization of the knee has been most gratifying. I t produces stability adequate for the stresses that may be applied by such a patient, In addition the knee is comfortable and allows motion adequate for activities of daily living. ISOLATED IGA DEFICIENCY IN JUVENILE RHEUMATOID ARTHRITIS Jam’es T. Cassidy and Ann Burt, Ann Arbor, Mich. Patients with congenital agammaglobulinemia or primary acquired hypogammaglobulinemia exhibit an increased incidence of chronic arthritis. Arthritis has not been associated, however, with Type I11 dysgammaglobulinemia. Immunoelectrophoresis of sera from 100 patients with juvenile rheumatoid arthritis identified 8 with no IgA precipitin arc. The current age range of this latter group was 5 to 23 years. Six were females. Serial determinations over 4 to 6 years in 6 of these individuals confirmed the persistence of this abnormality. Immunoassay indicated that 5/8 had no detectable IgA, and 3 /8 had decreased levels ( 0.07-0.52 mg/ml) . The concentrations of IgG and M were normal to increased. There was no IgA by electro-immunodiffusion in the parotid saliva, tears, or synovial fluid of 2 with agammaglobulinemia-A, and 0.04 mg/ml in the saliva of one with hypogammaglobulinemia-A. This same girl had positive rheumatoid factor tests. Antisera were prepared in rabbits to 2 immunodeficient sera, and cross-adsorption studies indicated that no antibody was induced to IgA. There was no correlation of IgA deficiency with clinical features of the arthritis. Family members had normal serum IeveIs of this immunoglobulin, except for one mother with low IgG, A and M. One of 146 randomly selected, non-hospitalized control subjects 1 to 20 years of age had no IgA. In retrospect this was a 14-year-old boy who had had transient arthritis at age 6. It was concluded that juvenile rheumatoid arthritis was associated with selective IgA deficiency in addition to the known increased occurrence of arthritis in classical, complete forms of hypo- and agammaglobulinemia. CHARACTERIZATION OF A TISSUE ANTIGENREACTIVEWITH LUPUSERYTHEMATOSUS ( L E ) SERA Geoffrey Clark, Morris Reichlin and Thomas B . Tom& Jr., Buffalo, N. The serum of a patient with a connective tissue syndrome closely resembling disseminated lupus, but with negative antinuclear antibody, was found to react with extracts of human tissue in Y. complement fixation and precipitin reactions. The antigen was purified IW-fold by DEAE chromatography followed by gel filtration. The antigen was present in only small amounts and precipitin 273 ABSTRACTS reactions required 10-fold concentration of the complement fixing activity in the original extract. It was not destroyed by trypsin, chymotrypsin, pepsin, papain, RNAase or DNAase. It was destroyed by heating at 70 ' for 30 minutes, periodate oxidation and . O M parahydroxy mercuribenzoate; the latter effect being partially reversible with cysteine. Gel filtration studies indicated a macromolecule of approximately 100,000 in molecular weight. The antigen gave a single precipitin arc in the a1 globulin region in immunoelectrophoresis when developed with LE sera. The serum factor was demonstrated to be a gamma globulin. Cell fractionation by a modified Chauveau method revealed that the activity was primarily in the soluble cytoplasmic high speed supernatant. A nuclear extract had little activity. It is distinct from known nuclear antigens including the system recently described by Tan and Kunkel (J. Immun. 96:464, 1966). The antibody was found in 40 per cent of unselected LE sera. This system is of interest because, unlike most of the previously described antigens reactive with LE sera, it appears to be cytoplasmic in origin and the antibody is present in certain sera in large amounts. AND SYNOVIAL ALTERATIONS IN SCLERODERMA SEROLOGIC J . A. Clark, R. K . Winkelmann, F. C . McDufie and L. E . Ward, Rochester, Minn. Rheumatoid factor was present in serum of 35 per cent of 265 patients with scleroderma. Sedimentation rate was normal in one-third, increased up to 40 mm. (Westergren) in one-third, and over 40 mm. in one-third of 401 cases. Lupus erythematosus cells were found in 4 of 230 sclerodermatous females but none of the 58 males; nucleolysis were found in 10 additional patients ( 2 males, 8 females). Serologic test for syphilis was positive in 5 per cent of 363 patients. Serum protein electrophoretic patterns (313 patients) generally were normal; gamma globulin was mildly increased in 26 per cent, rarely decreased. Synovial biopsies were performed in 36 patients. In 14 with negative rheumatoid factor (RF), generally there was much hyaline sclerosis and deposition of fibrin; in 22 with positive RF there was a tendency for somewhat less fibrin and sclerosis, and lymphocytic infiltration was somewhat more prominent. Five sclerodermatous patients with articular changes like those of rheum- DYNAMIC SPLINTINGOF atoid arthritis exhibited rheumatoid-like lymphocytic and plasma cell infiltrates in the synovial membrane. Synovial fluid in patients with negative serum rheumatoid factor tests generally was RF negative, mucin clot test was type 2 and ragocyte count was low, whereas in those with RF in serum the synovial fluid was RF positive, mucin clot was type 2 or 3, and ragocyte count tended to be slightly higher. Articular symptoms or signs were found in 77 per cent of 446 cases, mainly fibrositic stiffness of finger and medium sized joints, arthralgia, Iimited motion, tenderness, slight swelling and crepitation. Well-defined synovitis was less commonly detected clinically. Clinically-detectable synovitis tended to be more prominent in those with positive RF. Definite sclerodermatous x-ray changes were found in 25 per cent, suggestive changes in 36 per cent, rheumatoid-like changes in 3 per cent. THE RHEUMATOIDHAND F. Richard Conuery, 3. Pierce Conuty and Vernon L. Nickel, Downey, Calif. For the past 7 years, a dynamic hand splint designed to maintain motion, improve function, relieve pain and prevent the progression of deformity has been used on the arthritis service at Rancho Los Amigos Hospital. During the period 1959 to 1965, 61 patients with rheumatoid arthritis were fitted with this splint. Twenty-seven hands in 17 patients, who used the splints for more than one year with a mean duration of 34 months, are available for review. Thirteen hands in 8 patients, who were fitted but did not use the splints, and were followed for more than one year with a mean follow-up of 32 months, are available for comparison. The splints adversely affected wrist motion in those wrists that had had good extension. Wrist extension was not maintained, total range was reduced with a mean loss of 47 degrees, and significant wrist deformities developed in 3 wrists out of 13 that had had an essentially normal range. In the wrists with pre-existing deformity, the adverse effects were not so apparent. The wrists in the comparison group showed a mean loss of extension of 5 degrees and of total range of only 7 degrees. Twenty per cent of the MCP joints developed flexion deformities. Flexion range was lost in 39 per cent. Nineteen MCP joints had a passive flexion deformity at the onset of splinting. Of these, 8 improved, 8 were worse, and 3 did not change. The mean loss of total 274 ABSTRACTS range was 15 degrees. In the comparison group, there was no significant loss of total range, but flexion deformity developed in 12 per cent of the MCP joints. Splinting of the metacarpophalangeal joint seemed to adversely affect the proximal interphalangeal joint. There was a mean loss of motion of 17 degrees, which can be compared to 7 degrees in the nonsplinted group. Dynamic splinting of the rheumatoid hand does not prevent the progression of deformities, does not effectively correct pre-existing deformities, and in addition, probably results in limitation of motion that is greater than would be expected if the hand had not been splinted. ATYPICALSIGNSOF RHEUMATOIDARTHRITIS Joseph D. Croft, Jr. and Ralph F . Jacox, Rochester, N. Y. When unusual clinical and radiological signs of rheumatoid arthritis precede clinically apparent disease by several years, they may provide insight into the natural history of this disorder. Three such patients have been seen in our clinic. Two women developed a “ganglion” of the wrist, and the histologic appearance of these lesions was identical to the chronic synovitis seen in rheumatoid arthritis. Several years later both patients developed sero-positive rheumatoid arthritis. A third patient had a large bone cyst in the distal end of the right tibia. This lesion, when surgically removed, was, on pathologic examination, iudistinguishable from rheumatoid granulation tissue. RETENTION OF CRYOPRECIPITAUILITY I N THE During the subsequent 17 years, this patient has gone on to develop severe, erosive, and crippling arthritis with notable absence of advanced radiological changes in the ankle adjacent to the surgically excised cyst. The pathology and clinical aspects of these cases will be discussed. The above observations suggest that: 1) when “rheumatoid” ganglia are diagnosed, such patients should be closely followed for the development of rheumatoid arthritis and 2 ) rheumatoid disease should be included in the differential diagnosis of a large bone cyst even when no radiological evidence of adjacent joint disease exists. 5s PEPTIC FRAGMENT OF A CRYOGLOBULIN Norman A. Cummings, Houston, Tex. Cryoglobulins, serum globulins which reversibly precipitate in the cold, are found in a variety of connective tissue disorders and other disease5. The present project investigates the site on the molecule which is necessary for cryoprecipitation. A “7s” cryoglobulin was isolated from serum by of 6.61s at inficold precipitation. It had an, ,S nite dilution, gave a single homodisperse peak in the ultracentrifuge, a single symmetrical peak on gel filtration, and a single band against rabbit anti-human serum by immunoelectrophoresis. In a defined system, 30 per cent of the protein reversibly precipitated a t 0” C . The cryoglobulin was dige5ted with pepsin. The of 5.3s and a remaining fragment had an S, molecular weight of ahout 106,000. Under the same conditions used for the whole cryoglobulin, 15 per cent of the 5.3s protein reversibly precipitated at 0” C. Neither normal pooled fraction 11 (IgG) nor its 5s peptic fragment showed cryo- precipitability . Since heavy chains are generally less soluble than the native molecule, one might suspect a heavy chain site as being responsible for cryoprecipitability. However, it was observed that conditions needed to keep unaggregated heavy chains in solution inhibit cryoprecipitability even in the whole cryoglobulin. Heavy chains probably consist of a variable, and a relatively invariant, portion in terms of amino acid sequence. I t is the C-terminal, or invariant, portion of the heavy chain which hydrolyzed by pepsin and which is not needed for cryoprecipitation, although cryoprecipitability is enhanced by its presence. Further studies of structural alterations related to cryoprecipitation may be simplified by the use of the 5s peptic fragment rather than the whole molecule. THEEFFECTOF HEATWITH AND WITHOUTADDEDDIETARY SALT,ON S35 FIXATION BY CARTILAGE AND OTHERTISSUE Charles W. Denko, Columbus, Ohio Despite the climatologic universality of connective tissue disorders, arthritis patients, with or without medical advice, still seek benefits in warmer climates. Heat is frequently recommended 275 ABSTRACTS in treating arthritis in conservative programs. Localized and generalized heat, including baths, showers, packs, paraffin dips and heat lamps is used. Yet little information is available on the effects of heat on metabolism of cartilage and connective tissue, To determine whether or not generalized heat had any effect on connective tissues in the rat, animals were kept in incubators at 37°C for varying periods. Some received sodium chloride freely, while others were restricted during exposure to heat. The longest exposure was 8 hours daily, 5 days per week, for 3 weeks. S36 was injected as the metabolic tracer. Animals that were restricted in their salt intake had augmented levels of S35 incorporation in the aorta, adrenals, heart muscle, liver and kidney, This increase was about 50 per cent. No significant change was found in radioactive sulfate uptake by costal cartilage, tibia1 cap, stomach, spleen, colon and lung. When salt was freely available to the young rats, nearly all their tissues had normal levels of radiosulfur. Only lung and kidney had elevated uptakes. However, the level in costal cartilage was diminished, being one fourth less than in controls. Interpretation of these changes remains speculative. The lung and kidney are excretory organs that may be stimulated by heat. The inhibition of radiosulfur fixation in costal cartilage is similar to the effects produced by anti-inflammatory drugs. A CLINICOPATHOLOGIC STUDYOF THREEPATIENTS DYINGWITH THE SICCA (SJ~GREN’S) SYNDROME C . W. Denko, K . P. Clausen, C . Boesel, G . Penn and J . W. Old, Columbus, Ohio Few autopsies have been reported on patients dying with the sicca ( Sjogren’s) syndrome. Three such patients were studied recently to correlate ante-mortem clinical and biochemical abnormalities with histopathological changes. In addition to the sicca syndrome, several features were common to all: namely, polyclonal dysproteinemia, diffuse plasma cell infiltration of reticulo-endothelial organs, myopathy, and arthritis. The myopathy was manifest by weakness, myalgia, and wasting. All patients had taken steroids but the muscular lesion, fatty degeneration, was clearly not that usually reported with steroid therapy. After 6 years of therapy, one patient had clinical and autopsy evidence of improvement of her severe myopathy. A second had biopsy diagnosis of sicca myopathy and electromyographic evidence of diffuse myopathy. The third had clinical myopathy and myopathic lesions at autopsy iclentical to the first 2. The non-specificity of the lupus erythematosus (LE ) cell was illustrated in 2 of these patients with positive LE tests, macular skin rash, nodular colloid goiters and splenomegaly. Both were women who had clinical systemic lupus erythematosus, but had no histologic lesions diagnostic of lupus at autopsy. The male patient had a nonspecific collagen disorder most consistent with rheumatoid arthritis. All, however, had negative latex fixation tests. This study correlates the sicca syndrome with a specific myopathic lesion and demonstrates other common features of this connective tissue disease which are not typical of any classically defined rheumatic disorder. GLYCOSAMINOGLYCANS OF REGENERATING TENDON Robert W. Dorner, St. Louis, Mo. The connective tissue which forms following surgical excision of rabbit calcaneal tendon is suitable for study at various stages of maturity and eventually approximates mature tendon histologically. Pooled regeneration tissues from groups of 4 rabbits were obtained after regeneration periods of 4 days to 4 months. Aliquots of the pooled samples were used for the following studies: 1 ) cetyl pyridinium chloride (CPC) cellulose column methods for determillation of hyaluronate, chondroitin-4-sulfate, chondroitin-6sulfate, dermatan sulfate, and CPC complex solubility profiles; 2 ) Ecteola cellulose chromatography, mainly to determine keratosulfate; 3 ) total hexosamine determinations; 4 ) collagen solubility studies and disk electrophoretic determinations of collagen alpha/beta peptide ratios. The most pronounced changes in composition of the connective tissue took place during the first 3 weeks: hyaluronate decreased from about 50 per cent at 4 days to 20 per cent, and dermatan sulfate increased from about 10 per cent to over 40 per cent of the total CPC precipitahle glycosaminoglycans. Further, less rapid increases in dermatan sulfate and decreases in hyaluronate took place during the following 100 days. Chonclroitin-4-sulfate was found in variable concentrations in most of the regeneration tissues, but 276 ABSTRAtTS very little, if any, was found in 4-month regeneration tissue and in mature tendon. Chondroitin6-sulfate represented a relatively constant portion of the glycosaminoglycans of all regeneration tis- sues, as well as mature tendon. Four-month regeneration tissue had a composition approximating that of mature tendon. OF THE LOWERLIMBS REGIONAL MIGRATORY OSTEOPOROSIS Howard Duncan, Boy Frame, Harold Frost and A. Robert Arnstein, Detroit, Mich. A syndrome characterized by regional and migratory osteoporosis in the lower extremities occurred in 3 patients, either spontaneously or after mild trauma. Initially, there was pain and tenderness in the general region of the knee, ankle or foot, associated with a rapid progression of a spotty demineralization in the bones of the affected area. The pain was severe on weight bearing. There was edema, warmth, and evidence of increased vascularity of the overlying soft tissue. The clinical findings subsided in 6 to 9 months followed by improved mineralization of the involved bones. In all subjects, identical and sequential episodes of pain and spotty osteoporosis occurred over a period of 2 years in other areas of the same or opposite lower extremity without initiating cause. The same area was never involved with a second episode. Various forms of arthritis and general metabolic bone disease could readily be ruled out. The syndrome resembles Sudek‘s atrophy (reflex osteodystrophy) but is unique in that there is subsequent migratory and regional osteoporosis and soft tissue swelling of other areas in the same or opposite lower extremity. THECOMPARATIVE EFFECTSOF A DEXAMETHASONE AND A DEXAMETHASONE-ASPIRIN COMBINATION IN THE TREATMENT OF RHEUMATIC DISEASE DeWitt W. Englund and Sanford H. Roth, Phoenix, Ariz. This study was an attempt to conduct a clinical evaluation in order to show the relative benefits of dexamethasone and a dexamethasone-buffered-aspirin combination. Twenty nine patients were seen at the Phoenix Arihritis Center in this double blind study. Of these, 21 patients had rheumatoid arthritis. The remaining patients had osteoarthritis or other musculoskeletal conditions. Patients were given dexamethasone in a total daily dose of 0.75 or 1.5 mgs. as plain steroid, or in combina- tion with aspirin and aluminum hydroxide in the same relative amounts of dexamethasone. Following each 2-week course of therapy, patients were interviewed and examined. The severity of symptoms and physical findings was evaluated relative to the daily dose of dexamethasone, or dexamethasone-aspirin combination, and was recorded. Statistical analysis of the results shows the results shows the “steroid sparing” effect of the dexamethasone-aspirin combination compared to dexamethasone alone. INVITROEFFECTOF GOLDON LYSOSOMAL HYDROLASES R. S. Ennis, J . L. Granda and A. S. Posner, New York, N. Y. Recent evidence suggests that an important mechanism in the pathogenesis of rheumatoid joint disease is the labilization of lysosomes, with subsequent digestion and necrosis of joint cartilage. Persellin and Ziff postulate that the therapeutic effect of gold compounds in rheumatoid arthritis may be related to their effect on lysosomal enzymes. In the present series of experiments, intact lysosoma1 granules were obtained from rabbit liver by differential ultracentrifugation. Lysosomal stability was measured by incubation at p H 5.0, 37” C for 40 minutes. The addition of gold compounds ( thiomalate, thioglucose, chloride) did not protect lysosomes from disruption. Lysosomal acid phosphatase, ,8-glucuronidase and cathepsin were assayed in aliquots of liver lysosome fractions and in samples of human rheumatoid synovial fluid. I t was found that the gold compounds in concentrations ranging from 0.01-1.0 mg/ml inhibited the three enzymes by 50 per cent, 60 per cent, 50 per cent respectively. This inhibition is shown to be independent of pH, precipitation and chelation effects. Sulfhydrylbinding compounds ( iodoacetate, p-chloromercurybenzoic acid, mercuric acetate) are able to reproduce these inhibitory effects. In addition, it is shown that the gold inhibition of acid phosphatase and cathepsin can be diminished or reversed by the addition of a sulfhydryl compound (10 277 ABSTRACTS mmJL cysteine) to the system. Michaelis-Menton kinetics were determined for acid phosphatase and P-glucuronidase, including inhibition constants of the various gold compounds and sulfhydryl-binding agents. Gold com- pounds and sulfhydryl-binding agents act by a mechanism of non-competitive inhibition, Results suggest that one mechanism of action of gold in rheumatoid joint disease may be its ability to inhibit lysosomal hydrolases. EFFECTOF ADRENOCORTICOSTEROID THERAPY ON THE L-CHAINABNORMALITIES OF PATIENTS WITH SYSTEMICLUPUSERYTHEMATOSUS Wallace V. Epstein and Margaret Tan, San Francisco, Calif. The concentration of free L-polypeptide chains of immunoglobulins is strikingly elevated in the serum and urine of most patients with systemic lupus erythematosus ( SLE). Present evidence suggests that L-chain degradation is predominantly through kidney mediated catabolism. In all forms of renal insufficiency studied (120 patients), serum and urine concentrations of Lchain rise as the creatinine clearance falls. Some SLE patients without renal insufficiency have Lchain elevations as great as do patients with advanced renal insufficiency. Administration of adrenocorticosteroids to patients with SLE results in a fall in both serum and urine L-chain concentrations. 1125-labelled L-chain protein has been administered t o three patients with SLE having creatinine clearances over 77 ml/min. Despite elevations of endogenous L-chain pro- tein concentration, the time required to reduce protein bound radioactivity in serum to 5 per cent of the administered L-chain protein was only 6 hours. In contrast, a patient with SLE and a creatinine clearance of 44 ml/min required 19 hours to effect the same reduction while patients with advanced renal insufficiency or anephric individuals require approximately 78 hours. The administration of prednisone to patients in advanced renal failure fails to accelerate the rate of clearance of labelled exogenous L-chain protein; however, the endogenous light chain level is lowered. These results suggest that the elevated L-chain concentration seen in SLE reflects augmented production of L-chain protein either cle novo or by gamma globulin breakdown. In either case, the process appears responsive to adrenocorticosteroid administration. CHARACTERIZATION OF A COLLAGENOLYTIC ENZYME FROM CULTURES OF RHEUMATOID SYNOVIUM John M . Evanson, John J . Jeffrey and Stephen M . Krane, Boston, Mass. Although collagen degradation accompanies the chronic synovitis of rheumatoid arthritis (RA), previous attempts to identify enzymatic activity in extracts of synovial tissue and leukocytes which can break down native collagen fibrils have been unsuccessful. In the present study, this problem was approached by cultivating fragments of rheumatoid synovium obtained at operation on gels of reconstituted 14C-glycine labeled collagen, at neutral pIi, for 3 to 5 days, and measuring release of soluble radioactivity. Lysis of gels greater than trypsin controls was observed in synovial cultures from 8 of 10 subjects with RA. In positive experiments, explants contained abundant proliferating cells, similar morphologically to synovial cells, as well as lymphocytes; viable cells were scanty in cultures in which no collagenolytic activity was detected. Soluble enzyme was harvested from cultures of synovial tissue in modi- fied Eagle's medium. This enzyme had maximal activity at neutral pH (none at p H 5 ) and reduced the viscosity of collagen solutions at 27" C by approximately 60 per cent. Caseinolytic activity was negligible. Activity was linear with time and proportional to concentration of enzyme protein and was abolished by prior heating or treatment with EDTA. Reaction products at 27" C when examined by disc electrophoresis, electron microscopy and optical rotation showed that at this temperature the enzyme attacked the collagen molecule yielding 92 length fragments which retained helical structure. Thus, the reaction products resemble those produced by amphibian collagenase but are distinct from those produced by clostridial enzyme. Production of this collagenase by synovium may be important in the tissue destruction of RA. 278 ABSTRACTS INTRA-ARTICULAR RADIOACTIVE GOLD( 1DRAu) IN THE TREATMENT OF RHEUMATOID SYNOVITIS OF THE KNEE Paul H. Fine, Paul A, Farrer, Manfred Albrecht and Ralph F. Jacox, Rochester, N. Y. Surgical synovectomy may be a useful procedure in the treatment of persistent rheumatoid synovitis of the knee, but surgical removal of synovium is usually not complete and recurrences may occur. This technique may also be contraindicated in poor risk patients. The use of colloidal intra-articular radioactive gold (1QSAu)in the management of chronic synovial effusions has been reported by Ansell (1963) and Makin (1964). This study is designed to evaluate the effect of intra-articular colloidal 198Au on persistent rheumatoid synovitis with effusion of the knee. A total of 11 knees in 10 patients were treated. All patients had definite or classical rheumatoid arthritis with synovitis and effusion of the knee joint(s), persisting for a minimum of 6 months prior to treatment and not controlled by usual measures including systemic steroids in 8 of 1 0 patients. After aspiration of the effusion, 10 millicuries of lQ8Au in 10 cc. volume was injected. Serial scintillation scans revealed striking localization of radioactive material in both regional and distant lymph nodes and in the liver. The detectable levels of radioactivity in blood and 24-hour urine collections were small. The shape and size of the knee cavity were well defined on 24 hour joint scans. Additional data regarding joint fluid changes during the followup period will be presented. Four of 11 treated knees developed increased pain and swelling 7 to 12 days after injection. This rapidly subsided after rest and aspiration. Eight of 11 treated knees followed for 5 to 24 months have shown improvement in regard to pain and/or effusion. PLASMAGROWTHHORMONEAND URINARYHYDROXYPROLINE IN JUVENILE RHEUMATOID ARTHRITIS Chester W. Fink, Hugo Jasin, Roger Unger and Morris Ziff, Dallas, Tex. Growth arrest is common in juvenile rheumatoid arthritis. In an attempt to evaluate factors involved, a group of 13 affected children were studied. Growth rates were determined by sequential measurements of height, and disease activity assessed by clinical and laboratory evaluation. In addition, total urinary hydroxyproline was measured as a parameter of growth rate. In most cases, concomitant determinations of plasma growth hormone ( G H ) levels using a radioimmunoassay technique were obtained both in the basal state and during insulin induced hypoglycemia. Nine of 13 patients were growing actively; their urinary hydroxyproline levels were those of actively growing children and their maximum plasma GH levels were normal when compared with those of a group of 20 control children. None were receiving corticosteroids. Four patients were not growing and the urinary hydroxyproline levels were correspondingly low in 3. I n spite of lack of growth, 3 of 4 patients had normal GH levels. Two were receiving corticosteroid and one not. The failure to grow in the presence of adequate GH levels suggests a peripheral interference with growth. These results indicate that normal plasma growth hormone levels are found in most patients with juvenile rheumatoid arthritis whether growing or not. Absence of growth in the presence of adequate growth hormone levels suggests either a deficiency of “sulfation factor” or a lack of responsiveness of the “end-organ” involved in growth, due either to disease activity, corticosteroid effect, or both. ISOLATION OF BEDSONIA AGENTSFROM PATIENTS WITH UNCOMPLICATED NON-GONOCOCCAL URETHRITIS Denys K . Ford, Vancouver, British Columbia Urethral scrapings were obtained with a Dunlop-Jones curette from 30 patients with uncomplicated non-gonococcal urethritis attending the Vancouver Venereal Disease Control Clinic. These scrapings were inoculated into the yolk sacs of 6- to 8-day-old embryonated eggs, which were subsequently incubated at 35” C until the day prior to hatching. The eggs were then opened and the yolk sacs removed. Smears were made of the yolk sac material, and these were stained 279 ABSTRACTS with Gimenez modification of Machiavello’s stain. In 3 cases, one or more of the inoculated eggs showed elementary particles suggestive of Bedsonia agents, and on subsequent yolk-sac passages profuse growth of typical Bedsonia agents was obtained from each case. These agents have been assumed to be of the Trachoma-Inclusion Conjunctivitis type ( TRIC agents ). Employing a psittacosis antigen, complement- fixing antibody was demonstrable in the serum of 35 per cent of male patients attending the Venereal Disease Clinic and in 30 per cent of patients with Reiter’s syndrome. Attempts to isolate Bedsonia agents from 10 patients with Reiter’s syndrome have been fruitless up to the present, although in no case were optimal clinical specimens studied under optimal laboratory conditions. OF IGM ANTI-IGGFACTOFS USINGINDIRECT IMMUNOFLUORESCENCE DEMONSTRATION George J. Friou, Mita Ehn, Ronald Hill and Cecilia Gonzales, Los Angeles, Calif. In vitro inhibition of C‘ fixation by rheumatoid factor ( R F ) suggests function of RF or other anti-IgG antibodies in in vivo mechanisms modifying antigen-antibody induced inflammation. Antibody to autologous IgG altered by reaction with antigen appears more likely to function in such a mechanism than classical RF which reacts with more grossly altered IgG. We have investigated existence of antibody to autologous IgG bound to antigen using, as a model, immunofluorescent tests for antinuclear antibodies ( ANA), whole serum, and corresponding IgG and IgM fractions. Serums showing apparent IgG and IgM ANA were fractionated and tested further using 3 step immunofluorescence, rat liver sections or DNA or DNP spots, immunoglobulin specific rabbit serum and goat anti-rabbit conjugate. The studies (table) indicated anti-IgG activity in 9 of 27 serums, although only 4 of the 9 serums or IgM fractions yielded positive latex fixation tests. Conclusions: Results indicate that IgM antiIgG-factors may simulate IgM ANA. Studies of whole serum IgM ANA, and other IgM anti-tissue IgM ANA Anti IgG apparently IgM ANA activity Antigen present ( 1) confirmed ( 2 ) detected ( 3 ) spots: DNA 7 DNP 8 Liver speckled antigen 12 2 1 3 3 8 3 ( 1) Whole serum positive for IgM ANA ( 2 ) IgM fraction positive (3) IgM fraction negative alone, but positive when incubated on antigen, following IgG. antibodies, are therefore open to question. Occurrence of classical R F and antibody t o autologous IgG bound to antigen do not correspond. Study of this type of anti-IgG, rather than RF, may provide a useful approach to investigation of the in vivo role of anti-IgG in modifying complex induced inflammation. DECREASED CONCENTRATION OF HISTIDINE IN THE SERUM OF PATIENTS WITH RHEUMATOID ARTHRITIS-A NEW DIAGNOSTIC AID Donald A. Gerber and Marcia G . Gerber, Brooklyn, N. Y. Measurements have been made of the concentration of the amino acid histidine in the serum of patients with rheumatoid arthritis and control subjects by a simple new spectrophotofluorometric method which depends on the fact that histidine forms a fluorescent compound with o-phthaldialdehyde. The average concentration of histidine in serum from 57 patients with rheumatoid arthritis was 1.28 mg per 100 ml (S.D. = 0.4, S.E. = 0.05). The average concentration of histidine in the serum from 178 control subjects was 1.82 mg S.E. = 0.03). The difper 100 ml (S.D. ~0.4, ference between these 2 groups of patients is highly significant ( p 10-4). Stated in another < way, 71 per cent of the patients with rheumatoid arthritis, but only 5 per cent of the patients with other diseases, had a serum histidine concentration of less than 1.42 mg per 100 ml. In the control subjects there was no correlation between the concentration of histidine in serum and age, sex, sedimentation rate, or the presence of debilitating or chronic inflammatory disease. In patients with rheumatoid arthritis and in control subjects the administration of aspirin was not associatewith a decrease in the concentration of histidine in serum. No patients were studied who were receiving anti-inflammatory steroids or gold compounds, This study indicates that the concentra- 280 ABSTRACTS tion of histidine, as measured with o-phthaldialdehyde, is uniquely low in the serum of patients with rheumatoid arthritis, and is not related to inflammation per se or the administration of any drug. It is hoped that this measurement may help in diagnosing and understanding rheumatoid arthritis. ARTHROSCOPY AS A DIAGNOSTIC AND RESEARCH METHODIN THE RWEUMATIC DISEASES Jauier Robles Gil, Mexico City, Mexico Arthroscopy was performed in 30 patients: 13 with degenerative joint disease, 10 with rheumatoid arthritis, 2 with Jaccoud syndrome, and 5 with gout. The aim of the study was: 1) To learn more about the anatomo-pathological picture, as well as changes at the different stages of each disease. 2 ) To compare their similarities and differences. 3 ) To obtain a selected biopsy of the synovial membrane or cartilage guided by visual observation. 4 ) To study the macroscopic modification of the joint tissue lesions after the use of different drugs, as well as by histopathological studies. 5 ) To try t o elucidate the beneficial effects of the arthroscopy observed almost in every instance, through p H and enzymatic studies. The results, observation and conclusions are presented in different charts. Several pictures taken while the arthroscopy was performed illustrate the different subjects above mentioned. It was concluded that: 1) Arthroscopy can help in the differential diagnosis of some rheumatic diseases. 2 ) In some cases the arthroscopy can explain the lack of therapeutic response and even be helpful to establish better treatment. 3 ) Experimental work on joint tissue metabolism, as well as on the etiopathogenesis of rheumatic diseases, can be helped by arthroscopy. 4 ) Effectiveness of anti-inflammatory drugs or other therapeutic procedures can be evaluated with arthroscopy studies. 5 ) Various other observations and conclusions were withdrawn. CLINICALAND LABORATORY STUDIES OF HYPOPHYSO-ADRENAL RESERVE IN PROLONGED CORTICOTHERAPY Jauier Robtes Gil, Mexico City, Mexico The correct function of the hypophysis and suprarenal glands is essential to homeostasis. It has been stated that such function is seriously disturbed with prolonged corticotherapy. Two studies were undertaken. The first was designed to discover the incidence of clinical manifestations of adrenal insufficiency in 220 patients with rheumatoid arthritis ( R A ) , 35 with disseminated lupus erythematosus and 5 with progressive systemic sclerosis treated over more than 2 years with steroids. The second was an investigation of the hypophyso-suprarenal reserve through the ACTH and SU-4885 (Metopirone) tests in 20 RA patients with steroid therapy of 11 to 4?i years’ duration. After knowing the results of this investigation, the daily fractional steroid doses were changed to a single intermittent dose every 48 hours, for 12 weeks; the previous laboratory studies were also done in this group, always with a basal determination of ketogenic-steroid excretion (KCS) in the urine (Norymberski method). The results showed: 1) 50 per cent of the patients with continuous steroid treatment for less than 2?1 to 3 years had abnormally low KCS determinations after ACTH. 2 ) 62.5 per cent of the SU-4885 tests were low but as before a smaller percentage was observed after 2%to 3 years ( 2 8 per cent). 3 ) Considering the results of the combination of the two tests as the hypophyso-adrenal reserve, 75 per cent were negative in the patients with less than 3 years duration of therapy and only 28 per cent after. 4) The results of the tests after the intermittent treatment showed better hypophyso-adrenal function. The average KCS determination was 3.90 mg to 5.48 mg in the previous group. 5 ) The clinical incidence of hypophyso-adrenal dysfunction was rather low. The various manifeatations are shown in different charts. All the results are described in detail and illustrated, with slides. Some conclu4ions are withdrawn. 281 ABSTRACTS MEASUREMENT OF yG GLOBULIN ON COMPLEMENT COATEDREDCELLS Bruce C . cilliland, John P. Leddy and John H . Vaughan, Rochester, N. Y. RBC showing positive agglutination reactions with anti-complement sera and negative reactions with anti-y globulin sera have often been described in patients with connective tissue disorders, idiopathic acquired hemolytic disease or lymphomas. This has promoted the concept that there may be processes that lead to the attachment of complement components to the red cell surface without the participation of antibody protein. Alternatively, very small amounts of complement-hing antibodies may be involved. To investigate this further, a more sensitive method for the detection and quantification of yG globulin on the RBC was developed. Combining quantitative complement fixation with the antiglobulin consumption technique has made possible the detection of as few as 50 molecules of yG globulin per RBC, as evidenced by analysis with measured quantities of yG anti-A isoantibodies. This level of detection represents at least a 10fold increase in sensitivity over the direct antiglobulin test. Using this method, the complement-coated RBC's of 6 patients showing negative antiglobulin agglutination reactions with a potent anti-yG serum were investigated. In 4 patients, the quantities of yG globulin found were 75 to 200 or more molecules per cell. The other 2 patients, like normals, had RBC's with less than 35 molecules of yG per red cell. The increased quantity of yG globulin on the RBC's of 4 patients may represent complementfixing antibody. This possibility needs to be tested by attempts to recover specific antibody in concentrated eluates of such cells. The possibility that some complement-coated RBC's have present small quantities of yM antibody also merits investigation. OF UNILATERAL OSTEOARTHRITIS THE HIP J. P. Gofton, Vancouver, British Columbia Degenerative disease of the hip may be primary (idiopathic) or secondary to some predisposing cause. About N of idiopathic cases are, and remain, unilateral. No current hypothesis satisfactorily explains this condition. It is self-evident that a worn hip foreshortens the affected leg. I t is usually stated that the leg on the side affected is shorter than the contra-lateral one for this reason. Clinical observations of idiopathic unilateral osteoarthritis of the hip suggest that this is not always so. A series of cases has been measured for true leg length by an x-ray method with the patient standing. Unilateral osteoarthritis of a specific type ( superolateral) has a striking correlation with a long leg on the affected side; this is more impressive if allowance is made for some loss of leg length through degeneration and deformity of the hip joint on that side. Evidence will be presented upon which the following conclusions are based: 1 ) A significant number of cases of unilateral osteoarthritis of the hip, otherwise idiopathic, are associated with and presumably provoked by weight-bearing on a long leg. The greatly increased stress on the hip due to the mechanical disadvantage of this mild deformity will be discussed. 2 ) Degenerative osteoarthritis of the hip so produced differs in its pattern of onset and progression from other cases of degenerative hip disease. 3 ) The success or failure of osteotomy procedures should be reassessed with these foregoing considerations in mind. A rationale for the surgical procedure might be related to simple shortening of the affected leg, in some cases. 4) Theoretically, at least, this form of unilateral idiopathic osteoarthritis of the hip is preventable. INCREASED LYSOSOMES IN RHEUMATOID SYNOVUL CELLSIN TISSUE CULTURE Sidney Goldftscher, Carol Smith and David Hamerman, New York, N. Y. Earlier cytochemical studies of normal and rheumatoid synovial membranes showed markedly increased acid phosphatase activity in the lining cells of the rheumatoid membranes. Acid phosphatase activity, visualized in cytoplasmic granules, serves as a marker for lysosomes. The possi- bility was investigated that rheumatoid synovial cells maintain in culture the increased lysosomal enzyme activity they show in tissue sections. Cells from normal and rheumatoid synovial membranes were grown in nutrient medium with 10 per cent calf serum added, on cover slips in disposable 282 ABSTRACTS plastic petri dishes at 37” C in an atmosphere of 1 0 per cent CO,. Cells from 3 normal and 4 rheumatoid cultures were compared. Both normal and rheumatoid cells were studied as early as the second subculture, and as late as the seventh, after 5 months in continuous culture. The cells were washed in normal saline, fixed for 3 minutes in cold 2.5 per cent gluteraldehyde, and rinsed in distilled water. Acid phosphatase activity was visualized with Gomori’s lead medium, or Barka and Anderson’s azo-dye medium. Activity of another lysosomal enzyme, glucosaminidase, was visualized by Hayashi’s method. Rheumatoid cells from 4 different membranes displayed much more activity of these lysosomal hydrolases than cells from 3 normal membranes, and could readily be distinguished from the normal by this increased staining. Why increased lysosomal enzyme activity persists in the rheumatoid synovial cells through prolonged subculture is not known. In the rheumatoid synovial membrane enhanced phagocytosis of products from joint fluid was thought to explain the findings of large numbers of lysosomes of the residual body type. In tissue culture, the phagocytic capacity of the synovial cells appears quite limited, as judged by the failure of the normal and rheumatoid cells to take up from the medium the heme protein horse radish peroxidase. The elevated levels of lysosomal enzyme activities in the rheumatoid cells may possibly be due to the increased breakdown of intracellular constituents ( autophagic activity). OF THE KNEEWITH GOUTAND RHEUMATOID ARTHRITIS CHONDROCALCINOSIS Armin E . Good and Robert Rapp, Ann Arbor, Mich. A recent uncontrolled study reported radiographic evidence of meniscal calcification in 10 of 31 patients with gout (New Eng. J. Med. 275: 754, 1966). Although the calcium deposits were not noted to be as heavy as those reported in cases of pseudogout, this study has cast some doubt upon the value of this sign in the differentiation between gout and pseudogout. Using a “blind’ technique, we examined for the presence of soft tissue calcification knee films of 43 patients with proven gout intermingled with a control series of films from 38 patients with classical rheumatoid arthritis. Five cases were found with definite, extensive calcification of menisci, 2 from the gout series and 3 from the rheumatoid. In addition, 2 gout and one rheumatoid case were found with faint, focal, meniscal calcification. The prevalences of definite chondrocalcinosis in the gout series (5 per cent) and the rheumatoid ( 8 per cent) are nearly the same as those reported elsewhere among unselected nursing home inmates and from a large cadaver population. We could not confirm an increased association of gout with either definite or faint chondrocalcinosis. THE PHARMACOLOGY OF MYOCHRYSINE ( SODIUMAUROTHIOMALATE ) INJECTED BY THE INTRA-ARTICULAR ROUTEIN PATIENTSWITH RHEUMATOID ARTHRITIS Norman L. Gottlieb and Edward M . Smith, Miami, Fla. Based on the work of Lewis and Ziff (Arthritis Hheum. Y:682, 1966), we have instituted a longterm prospective study to investigate the pharmacology and efficacy of intra-articular injections of hlyochrysine. This material has been labeled with radioactive gold-195 and combined with the nonradioactive pharmaceutical substance. The labeled material has been shown to behave biologically in the same manner as the nonradioactive drug. Subacutely inflamed knees of patients with classical rhcumatoid arthritis (as defined by ARA criteria) were injected with a single 50 mg. dose o f labeled Myochrysinc (25 mg. of gold). These patients had not received any form of gold therapy in the past, a n d the only anti-inflammatory medication they were receiving was salicylates. Thc contralateral knees were used as controls. The rate of disappearance of the radionuclide from the knees and concurrent rate of appearance in snmples of blood, urine, and synovial fluid were determined. In addition, kidneys and other joints and organs were monitored for their level of radioactivity. Also the spatial distribution of the radioactive gold in the region of the knee at various intervals of time was evaluated using a multicrystal rectilinear scanner. The rate of disappearance of gold from the knee joint was represented by a curve with at least three components; 50 to 70 per cent disappeared with a half-time of less than 4 hours, 15 to 25 per cent with a half-time of approximatcly 1 day and the remaining with a half-time of greater than 20 days. Soon after injection, thc radioactive gold could be measured in the blood, and reached a maximum at 4 to 6 283 ABSTRACTS hours. The disappearance curve consisted of one component with a half-time of between one and two days comprising 30 per cent of the maximum activity and the remaining disappeared with an 8- to 10-day half-time. The kidneys contained between 10 and 20 per cent of the injected activity, which was slowly eliminated. The major route of excretion appears to be urinary. Synovial fluid aspirated from the injected joint contained radioactive gold. When the fluid was allowed to clot, no significant amount of activity was detected in the clot. No significant amounts of gold could be detected in the organs or joints. OF SEPTICARTHRITIS CALFCYSTABSCESS-AN UNRECOGNIZED COMPLICATION Anthony P . Hall and L. A . Healey, Seattle, Wash. The causes of calf swelling in patients with rheumatoid arthritis have been delineated by Hall and Scott (Ann. Rheum. Dis. 25:32, 1966). Hench described dissecting popliteal cyst simulating thrombophlebitis at this meeting in June, 1966. We have seen 4 patients with infection in a synovial cyst of the calf as a complication of septic arthritis of the adjacent knee. Two of these patients had rheumatoid arthritis and 2 had diabetes mellitus. In all 4, the painful swollen calf was initially interpreted as thrombophlebitis. In one patient, the abscess was demonstrated by needle aspiration of the calf swelling and positive contrast arthrography outlined a large cyst communicating with the knee joint. This patient also had a huge infected cyst of the upper arm which was shown by arthrography to connect with the olecranon bursa. One of the 4 patients had an infection due to an unusual organism, Serratia marcescens, that did not respond to antibiotics. The calf cyst abscess was not detected until his leg had been amputated above the infected knee. In all of these patients, fever and other signs of infection were not controlled until the infected cyst was recognized and drained. ABNORMAL RENALFUNCTION IN RHEUMATOID ARTHRITIS L. A. Healey and Roger 1. Bulger, Seattle, Wash. Renal function tests were performed in 42 ambulatory patients with definite rheumatoid arthritis. None of the patients had diabetes mellitus or systemic lupus erythematosus. Abnormalities were found in 22 patients. Sixteen of them had a 24-hour creatinine clearance of less than 80 cc/min. Inability to concentrate the urine after a 12-hour fast (specific gravity <1.018) was present in 19. Two patients had red cell casts and 11 had granular and white cell casts. Only 2 had proteinuria and none showed nitrogen retention. Eleven patients were diagnosed as interstitial nephritis, 2 as glomerulonephritis, and 9 were unclassificd. No evidence of infection, amyloidosis or papillary necrosis was present. The 22 patients with abnormal tests did not differ from the 20 patients with normal function as to age, sex, duration or severity of arthritis, presence of rheumatoid factor or the type of medication. Only 2 patients, both with normal tests, had taken any phenacetin. All had taken aspirin. The estimated total aspirin intake was greater in the patients with abnormal tests, 93 vs. 66 tablet/ years (p<0.05). In this study, abnormal renal function tests were found in 22 of 42 patients with definite rheumatoid arthritis. An association with prolonged aspirin intake is suggested but not proven. THE ALTERATIONOF SERUMALBUMINn Y ACETYLSALICYLIC ACID P . Kahler Hench and Richard 5’. Farr, La Jolla, Calif. Previous studies employing equilibrium dialysis and anion exchange chromatography have demonstrated that sera from patients with rheumatoid arthritis (RA) have a greater affinity for low concentrations of 1131-labeled sodium acetrizoate than do normal sera. The factor responsible for increased acetrizoate binding has been char- acterized as an altered albumin. Although no correlation exists between acetrizoate binding and salicylate levels in randomly selected sera from patients with RA, it has been found that albumin from normal individuals binds significantly more acetrizoate following: 1) the ingestion of 2.4 grams of acetylsalicylic acid ( A S A ) per day for 284 ABSTRACTS 21 days; or 2 ) dialysis against ASA in vitro. Albumin thus altered by ASA does not revert to normal after dialysis against saline. Many other medications tested, including sodium salicylate, do not enhance acetrizoate binding. To learn if all in vivo increases in acetrizoate binding are due to the ingestion of ASA, 13 patients with RA taking 3 to 5 grams of ASA per day were changed to an equivalent dose of sodium salicylate. The acetrizoate binding fell significantly in 11 and remained unchanged in 2. Serial deter- minations in 4 patients indicate that the half-life of the albumin responsible for increased acetrizoate binding is 15-22 days. The observation that the acetrizoate binding did not decrease in 2 patients after changing from ASA to sodium salicylate suggests the possibility that a metabolite associated with RA may structurally alter albumin in a manner similar to ASA. It remains to be learned whether alteration of albumin during treatment with ASA is beneficial or detrimental to the patient. TREATMENT OF ALKAPTONURIA AND OCHRONOTIC ARTHRITIS WITH A Low PHENYLALANINE-LOW TYROSINE DIET Donald E. Holdsworth, Margaret L. Barry and Judith L. Swyter, Boston, Mass. Alkaptonuria is a rare metabolic error which results in the disease ochronosis. Previous attempts at treating this disease by limiting protein intake have been unsuccessful. This paper reports the successful application of a low phenylalanine-low tyrosine diet to a brother and sister afflicted with alkaptonuria and ochronotic arthritis. The basic diet was a low phenylalanine-low tyrosine food powder based on a specially processed enzymatic hydrolysate of casein. Except for phenylalanine and tyrosine the food powder was nutritionally adequate. The formula was supplemented with selected foods low in phenylalanine to add variety and provide bulk. The final composition diet was 1700 calories, 227 gms. carbohydrate, 65 gms. fat and 56 gms. protein. The formula supplied 8 per cent of the protein and 75 per cent of the calories. The total phenylala- nine content was 772 mgs. In both patients there has been clinical improvement characterized by decrease in joint pain and stiffness. In one patient, recurrent joint effusions are no longer apparent and distressful bouts of atrial fibrillation are now a rarity. Twenty-four hour urinary excretion of homogentisic acid in the 2 patients has been lowered from pre-treatment levels of 1540 mgs. to 700 mgs. and from 2000 mgs. to 850 mgs. respectively. Observation over a 9- and 18-month period has revealed maintenance of normal nutrititon and continued improvement in their arthritic status. Case summaries and metabolic data will be presented. I t is believed that this may be the first report of a diet which can be of benefit to patients afflicted with this disease. RATEOF DNA SYNTHESIS BY BLoon MONONUCLEAR CELLSIN INFLAMMATORY DISEASE D. A. Horwitz, P. Stastny and M . Z i f f , Dallas, Tex. Since mononuclear cells of the blood are known to incorporate tritiated thymidine (H3Tdr) actively in tissue culture under certain conditions, experiments were carried out to examine the rate of such incorporation in human buffy coat cells of patients with inflammatory disease. Ten million washed buffy coat leukocytes were cultured for 5 hours in minimal essential medium containing 15 per cent human serum and 1 pc/ml. tritiated thymidine. The radioactivity incorporated was determined by scintillation counting and the results expressed as counts per total mononuclear cells in the sample (100 x C.P.M./per cent mononuclear cells). The mean H3Tdr uptake of 11 healthy volunteers was 51 ( 15-72). Four patients with miscellaneous non- inflammatory disease (aseptic necrosis of the hip, arteriosclerotic heart disease, cerebrovascular disease and hyperthyroidism) had a mean uptake of 66 (20-88). The mean H3Tdr incorporation of 15 patients with systemic lupus erythematosus was 445 (681580). In 2 patients with acute rheumatic fever, uptakes were 99 and 116 respectively; one patient with mixed collagen disease had a value of 465. The mean uptake of 5 patients with hepatitis was 232 (73-372) and 4 patients with tuberculosis, 186 ( 1 0 0 3 7 0 ) . When the buffy coat cells of 4 patients with inflammatory disease (SLE 2; exfoliative dermatitis, l; and acute rheumatoid arthritis, l ) were cultured on admission, mean H3Tdr uptake was ABSTRACTS 880 (408-1415).With the onset of clinical improvement, this decreased to 270 C.P.M. (44575). There was no correlation of H3Tdr incorporation with the erythrocyte sedimentation rate or the levels of total globulin, a2 globulin, or y globulin when these were measured at the same time. These preliminary findings of increased DNA synthesis by blood mononuclear cells in inALTERATIONS flammatory states are of interest in view of a previous observation that a large fraction of mononuclear cells which localize in inflammatory sites are of hematogenous origin and have recently synthesized DNA. Studies are in progress to determine whether the technique described may serve as an index of inflammatory activity in disease. COMPOSITION OF GROWTH CARTILAGE SEPTA DURINGCALCIFICATION BY MICROSCOPIC X-RAY ELEMENTAL ANALYSIS-IN STUDIED CORRELATIONWITH BIOCHEMICALSTUDIES IN THE D. S . Howell, L. Carlson and E . Deldiamps, Miami, Fla. and Stockholm, Sweden Distribution of total mass, S and P measured by x-ray elemental analysis in microscopic sites at the zone of provisional calcification and adjacent to uncalcified cartilage septa permitted a quantitative estimation of changes in sulfated glycosaminoglycans, as well as organic and mineral phases. Onset of calcification within the cartilage septa was identified by a sharp increase in concentration of P and total mass per unit area of histologic sections in measurements progressing from the proliferating cell zone to the metaphysis. P concentration was 2 to 3 per cent within proliferating and hypertrophic cartilage cells and 4 to 5 per cent at proliferating cell margins with elevated total dry mass. Despite negative Von Kossa stains in this zone, the findings are strongly suggestive of a mineral phase. The concentration of P was 1.7 per cent in hypertrophic cell septa, and 0.4 per cent in the central regions of the proliferating cell septa. Results of biochemical study of phosphate, partitioned in these tissues, as well as a comprehensive electrolyte profile measured on similar cartilages previously were entirely consistent with the current x-ray elemental analysis. There was a slight decrease of S and a larger decrease of organic per-unit area of intact histologic section in progression of measurements from uncalcified to calcified cartilage septa1 matrix. The abrupt changes in the organic composition at the boundary of the calcification front at the margins of proliferating cells are believed to be related to biochemical steps in calcification. A working hypothesis concerning biochemical pathways of endochondral calcification will be presented and their close relationship to similar processes in remodeling of articular cartilage explained. TRANSIENT UNILATERAL OSTEOPOROSIS OF THE HIP: A CLINICALSYNDROME? Gene G. Hunder and Patrick I. Kelly, Rochester, Minn. Existence of a relatively unrecognized clinical syndrome is suggested by the association, in 8 patients, of 1) osteoporosis involving only one hip, 2 ) pain during weight bearing, 3 ) absence of apparent local or systemic cause, and 4) recovery after a period of bed rest. In 6 men and 2 women, ages 35 to 52, pain developed in one hip and persisted 2 to 6 months. Pain was most noticeable during or after weight bearing. Limitation of motion of the affected hip was the only pertinent physical finding. Roentgenograms of all painful hips showed marked osteoporosis of the femoral head and often the femoral neck and acetabular bones. Joint space and contour of the femoral head remained normal. Half the patients had increased erythrocyte sedimentation rates. Other laboratory results were normal. Arthrotomy was done in all cases. Grossly, joint capsules were thickened or synovia were injected in 5 of 8 cases, but microscopically the synovial membrane appeared normal or showed only minimal chronic inflammation in all cases. Bone biopsies obtained in 4 cases showed necrosis, resorption, and new hone formation. Cultures of synovial tissue and fluid were negative. Functional recovery of the hip and disappearance of pain were complete in all cases after convalescence following arthrotomy ( 2 to 12 year follow-up ) . Osseous recalcification occurred in all 7 cases with available follow-up roentgenograms. Similar episodes of osteoporosis later developed in one patient’s shoulder and another patient’s foot. Recognition and study of more cases of this syndrome may amplify and explain these unusual findings. 286 ABSTRACTS RENAL INVOLVEMENT IN SYSTEMICLUPUS ERYTHEMATOSUS: CLINICALAND BIOPSYFINDINGS Eric R. Hurd, Stanley W. Strunk and Morris Zifl, Dallas, Tex. Of 37 patients with systemic lupus erythematosus (SLE ), 24 (64 per cent) initially demonstrated clinical evidence of renal disease. Of the 13 patients with negative findings, 7 continued negative for an average of 5.9 years (3.0-10). However, 6 ( 1 6 per cent of the overall group) developed clinical renal disease after an average of 2.2 years (0.8 to 3.8). This late development of renal disease is significant in view of previous reports that nephritis in SLE, if not present at onset, is not likely to develop later. When clinical data and renal biopsy at onset of SLE were correlated, 11 of 14 patients with positive clinical findings showed definite histologic abnormalities and 3 showed minimal changes: i.e., none was normal. In 8 patients with negative clinical findings, the biopsy was normal in 6 and showed minimal glomerular changes in 2. Electron microscopic examination of biopsies taken at onset in all of 10 patients with positive clinical findings and 7 of 8 with negative clinical findings showed electron-dense deposits in the glomerulus. I n the same group, 10 of 10 biopsies with positive histology and 4 of 6 with negative histology also showed electron dense deposits. Serologic studies were performed. In view of the suggestion that rheumatoid factor protects against nephritis in SLE, it is of interest that latex fixation tests were negative in all 6 patients with persistently negative renal findings. The results described demonstrate 1) the uniform presence of histologic abnormalities in patients with clinical renal disease; 2 ) absence of histologic changes but presence of ultrastructural abnormality in most patients with negative clinical findings; and 3 ) an impressive correlation between the results of clinical and histologic evidence of nephritis. SYNOVIAL LININGCELLSYNTHESIS OF A SUBSTANCE IMMUNOLOGICALLY RELATEDTO CARTILAGE PROTEINPOLYSACCHARIDE Rosamond Janis, John Sandson, Carol Smith and David Hanzerman, New York, N. Y. The proteinpolysaccharides (PP ) of cartilage matrix have at least two antigenic determinants. One is shared by PP from human, pig, and bovine cartilages, and has been called the common site. The other determinant is found only in cartilage PP from the particular species, and is called the species-specific site. When rabbits are immunized with human cartilage PP, the antiserum obtained forms 2 lines on agar diffusion against human cartilage PP, indicating reactions with both the specific and common site. If the antiserum is absorbed with bovine cartilage PP and tested against human cartilage PP, only a single precipitin line is observed, for the antiserum now reacts only with the species-specific site. Synovial fluids contain a component immunologically identical with the species-specific site of cartilage. This component is present in normal and many pathological fluids, but is diminished in chronic rheumatoid effusions. It can be separated from hyaluronate by zone electrophoresis and migrates in the ,8 globulin zone. An immunofluorescent study of human synovial membrane sections was performed using the specific antiserum and a fluorescein-labeled goat anti-rabbit globulin. Bright fluorescence, indicating a component reactive with antiserum to the species-specific site, was localized in the lining cells of the normal synovial membrane, but staining was diminished in rheumatoid membrane lining cells. To exclude the possibility that the lining cells merely phagocytize the species-specific component from the joint fluid, the same immunofluorescent study was carried out with synovial cells in tissue culture. These cells, too, showed bright fluorescence. Furthermore, the species-specific component was identified in the culture medium by agar diffusion studies. Thus, the synovial membrane lining cells secrete a substance immunologically identical to the speciesspecific site of cartilage PP, and for reasons not yet understood, this function is diminished in rheumatoid arthritis. THE CARDIOVASCULAR AND PLASMA CORTISOL RESPONSE TO SYNOVECTOMY OF THE KNEE IN CORTICOSTEROID-TREATED RHEUMATOID PATIENTS M . K . Jasani, P. A. Freeman, J . A. Boyle, M . J . Diver, A. I . M . Reid and W . W . Buchanun, Glasgow, Scotland Understanding of the prevalence and site of involvement of the hypothalamo-pituitary-adre- nal (HPA) axis in patients with rheumatoid iirthritis receiving oral corticosteroid drugs has 287 ABSTRACTS increased recently with the availability of several methods of testing the functional integrity of this axis, such as the Synacthen (tetraicosapeptide P I - 2 4 ) , lysines-vasopressin, insulin-induced hypoglycemia, and metyrapone tests. The purpose of the study was to determine the effect of surgical stress in corticosteroid-treated rheumatoid patients on their plasma cortisol and cardiovascular responses, and to correlate these responses with the results of tests of the HPA axis. Measurements of plasma cortisol, pulse rate, and blood pressure were carried out before, during, and after anterior synovectomy of the knee in 40 rheumatoid patients, 20 of whom were receiving long-term oral corticosteroid therapy; the remainder, who had never received corticosteroid therapy, served as controls. The anaesthetic procedure and the operation time was the same in both groups: the synovectomies were performed by one surgeon. The corticosteroid-treated patients received their last dose of corticosteroid 18 hours before operation, and therapy was resumed 6 hours after operation. The results show that as a group the corticosteroid-treated patients had significantly poorer plasma cortisol responses, and had slightly lower blood pressure responses. Ten of the corticosteroid-treated patients with definite adrenal suppression as tested by Synacthen had plasma responses which lay below the lower limit of the 95 per cent confidence limits of the plasma cortisol responses in the control patients; and one developed hypotension which required treatment with intravenous hydrocortisone. The remaining 10 corticosteroid-treated patients with normal Synacthen tests, and with either normal or abnormal lysines-vasopressin, insulin hypoglycemia and metyrapone tests, were found to have normal plasma cortisol responses to surgery. The practical and theoretical implications of these studies will be discussed. SJOGHEN’S SYNDROME, MONOCLONAL MACHOGLOBULINEMIA AND ACCELERATED IGG CATABOLISM John S. Johnson, Thomas A. Waldmann and Norman Talal, Bethesda, Md. Reports from this institute have described the development of malignant lymphoma and pseudolymphoma in certain patients with Sjogren’s syndrome. Patients with pseudolymphoma have unusual extraparotid lymphoproliferative infiltrates and, frequently, elevated serum IgM concentrations. A patient is reported with Sjogren’s syndrome, pulmonary lymphocytic-plasmacytic infiltrates, cryogelglobulinemia, elevated serum IgM, reduced total hemolytic complement (C’H,,) and a clinical course characterized by repeated infections. Her “cryogelglobulin” consists of 18s IgM and 7s IgG. The isolated IgM component was shown to possess light polypeptide chains of a single antigenic type ( K ) and to be highly homogenous by other techniques. Specificity of the isolated IgM for IgG was demonstrated, as well as its failure to interact with IgA and other non-immunoglobulin serum proteins. This IgM thus behaves like a “monoclonal” Waldenstrom-type macroglobulin with rheumatoid factor specificity. Serum protein metabolic studies revealed a normal survival of IgM, IgA and albumin, but a markedly reduced survival of IgG. It is suggested that the catabolism of IgG complexed with IgM is a significant factor in the reduced serum IgG concentration. AVASCULAR NECROSISOF BONEIN ALCOHOLISM John Paul Jones, Jr. and Ephraim P. Engleman, San Francisco, Calif. Osseous avascular necrosis was discovered in 25 patients with alcoholism. Avascular necrosis was diagnosed roentgenographically in all cases and confirmed histologically in 16 patients. The triad of alcoholism, fat embolism and avascular necrosis may represent a new syndrome, since in no instance was there major antecedent trauma or known systemic condition( s ) associated with nontraumatic avascular necrosis. Necrosis was found in 37 femoral heads and in 6 humeral heads. Earliest roentgen abnormalities appeared within 12 months after joint pain and stiffness were reported. Metadiaphyseal lesions were generally asymptomatic and appeared in the distal femur ( 6 ) and proximal tibia (8). We have previously shown experimentally that fat emboli occlude terminal intraosseous capillaries with resultant micro-infarctions. Several patients experienced unexplained pneumonitis, hypertension and hypertriglyceridemia. Of 15 patients studied, probable systemic fat embolism was established by detecting lipuria in 7, of whom 288 ABSTRACTS 2 had intravascular fat within resected femoral heads. The alcohol-induced fatty liver is probably the commonest source of continuous or intermittent low-grade showers of systemic fat emboli. Twenty patients showed significant hepatomegaly and bromsulphalein retention. Five of 7 livers demonstrated fatty metamorphosis histologically. One patient with a biopsy-proven fatty liver, hypertriglyceridemia and lipuria spontaneously devel- oped unilateral groin pain and the earliest tomographic manifestations of necrosis. Intraosseous phlebography and intramedullary manometry suggested avascularity, and biopsy revealed avascular necrosis of the femoral head. Another patient with alcoholism, who had prior metadiaphyseal bone infarctions, suddenly expired. Autopsy demonstrated marked hepatic steatosis, fat embolism and early avascular necrosis of a femoral head. UNEXPECTED RADIOGRAPHIC CHANGES OF THE HIP JOINTFOLLOWING LUMBARSYMPATHECTOMY FOR ARTHRITIS W . H . Kammerer and T . I . Hoen, New York, N. Y. Since 1927 sporadic reports have appeared in the medical literature regarding the beneficial effects of lumbar sympathectomy in the relief of pain of arthritis of the weight-bearing joints. From 1960 to the present 16 patients with severe painful arthritis of the lower extremities have had lumbar sympathectomy at The Hospital for Special Surgery. All were women ranging in age from 25 to 80 years. Nine had rheumatoid arthritis, 7 had degenerative joint disease. Fourteen remain under observation or have been contacted. Hip joint pain was relieved completely or almost so in 6 patients, in 6 there was no benefit, in 2 the immediate result was excellent but they have been lost to observation, and in 2 the immediate result has been excellent but follow-up is less than 6 months. In 1966 a patient with classical rheumatoid arthritis was admitted to hospital for a synovectomy of the elbow. She had had a right lumbar sympathectomy in 1962 for severe right hip pain which resulted in relief of pain and increased functional ability in this joint. An x-ray of the pelvis, done at the time of the second admission, revealed a startling improvement in the radiographic appearance of the right hip consisting of remolding of the joint, improvement in the texture of the bone and increase in joint space. Following this unexpected finding, x-rays of other patients who had had successful outcome of sympathectomy were obtained and these will be presented. THEINHIBITION OF ADJUVANT ARTHRITISBY STATOLON M . A. Kapusta and J. Mendelson, Montreal, Canada An immunological basis for adjuvant induced arthritis is commonly accepted, although the role of viral and/or Bedsonia organisms as etiological agents in this model has not been excluded. Statolon is a broad spectrum antiviral-antibedsonia agent which probably acts through the mediation of interferon produced in the recipient animal. In the present study an attempt has been made to alter the course of adjuvant arthritis with statolon to provide insight into pathogenetic mechanisms in this experimental model of arthritis. Sprague Dawley and Charles River strains of rat were used in all studies. Arthritis-producing doses of modified Freund’s adjuvant ( M . F . A . ) were administered to 4 groups of rats and their clinical course followed. Statolon was given intraperitoneally in 10 mgm. doses. 1 ) Controls-no statolon. 2 ) One injection of statolon 24 hours prior to the administration of M.F.A. 3) Pre M.F.A. statolon plus a second dose one week later. 4) Pre M.F.A. statolon plus 2 further doses one week apart. The severity of arthritis was graded in all rats, 21 days post-induction, on an arbitrary scale of 1 to 20 by “third party” observers. The average scale results were: Group 1, 15.3, Group 2, 16.9, Group 3, 11.7, and Group 4, 1.7. Group 4 did not develop increased acute joint involvement or deformities for 2 months following the last dose of statolon. Gross and histological comparisons will be presented. These results indicate the protective effect of statolon on adjuvant arthritis, and suggest a possible role for a true virus or Bedsonia group of organism in the pathogenesis of this experimental disease, and indirectly a possible role of interferon in its modification. 289 ABSTRACTS LONG-TERM CAREOF THE ARTHRITIC lrving Karten, A. Oscar Koatz and Currier McEwen, New York, N. Y. Rehabilitation of the patient with advanced rheumatoid arthritis is exceptionally difficult because of the severe mechanical limitation produced by joint deformities and the uncertain course of the disease activity. Pain and limited tolerance for exercise further contribute to an unpredictable prognosis. Rehabilitation becomes a life-long process in which goals are determined by a changing disease. Early cases may respond well to treatment in outpatient centers or in acute hospitals, but the severely deformed patient is exhausted by the time he dresses and travels to a clinic, and when hospitalized he needs long-term care at a tempo that will permit optimum rehabilitation. Nursing homes, chronic care institutions and other extended-care facilities would be suitable for the arthritic if properly staffed and if the atmosphere of custodial care could be replaced by one of active treatment with patients in whom some improvement could reasonably be expected. In the past 2% years we have organized a pro- gram for older arthritics with longstanding disease on a 30-bed ward of a chronic care hospital. Fifty-eight patients with rheumatoid arthritis have completed treatment, lasting a mean of 3% months and consisting of medical supervision as well as occupational and physical therapy provided on the ward. As a group the patients showed advanced deformities and could perform few of the activities of self care or were restricted to a wheelchair. Functional improvement on an Activities of Daily Living scale was obtained in approximately half of the most severely disabled patients. Seventeen of 31 wheelchair patients accomplished at least partial ambulation. Of the 58 patients, 3 died while under treatment and 6 died during the follow-up period extending from 2 months to 2 years. Rehospitalization was required for 7 additional patients, and 6 additional patients eventually required custodial care. THEARTHRITISOF ABORTIVESARCOLDOSIS Warren A. Katz, Hubert I . Caplan and Mayer Rubinstein, Philadelphia, Pa. and Boston, Mass. The syndrome of bilateral hilar adenopathy, erythema nodosum, and polyarthritis is well established. Although the etiology is uncertain, evidence has accumulated indicating that this disorder is probably a hypersensitivity reaction presenting as an abortive form of sarcoidosis. The presence of the characteristic nodose lesions in a young adult with joint disease strongly suggests the diagnosis, while the finding of hilar adenopathy on chest x-ray confirms it. I t is the purpose of this report to discuss a similar group of 19 patients who presented primarily with articular manifestations, The key feature of erythema nodosum, however, was absent. An incorrect initial diagnosis, therefore, resulted in almost every case. Subsequent chest x-ray in all patients and biopsy material in 80 per cent confirmed the existence of sarcoidosis. Clinically the patients formed a fairly homog- enous group with regard to age, onset of symptoms, generalized manifestations, and polyarthritis. The ankle, the most commonly involved joint, usually presented with characteristic clues pointing to the correct diagnosis. These included marked periarticular inflammation with striking tenderness despite the absence of pain on motion. The erythrocyte sedimentation rates and serum globulins were usually elevated, but the antistreptolysin titers were normal. The disease ran its course in several months, and almost all patients were asymptomatic and free of hilar adenopathy within one year. Because of the tendency of this syndrome to mimic other rheumatic diseases, particularly acute rheumatic fever and rheumatoid arthritis, and because of its favorable prognosis, early diagnosis and conservative therapy are important. URINARYACID MUCOPOLYSACCHARIDES AS A MEASURE OF ACTIVITYIN RHEUMATOID ARTHRITIS Ronald L . Kaye, L. Emmerson Ward and John V . Roseoear, Palo Alto, Calif. and Rochester, Minn. A modified method of determining the urinary acid mucopolysaccharide (AMPS) excretion is defined. The quantitative measurement is ex- pressed on the basis of urinary creatinine, so that the test can be done on a random urine sample. Normal upper limits for this value are presented 290 ABSTRACTS from study of control groups of 27 men and 21 women. The control groups were studied for age and sex influence, daily excretion variations, and influence of the time of daily collection. The method was found to be reproducible and not significantly affected by these variables or diet. Fifty-three patients with classic or definite rheumatoid arthritis were examined clinically and by various laboratory parameters. The patients were assessed as clinically active or inactive by experienced rheumatologists on the basis of fibrositis, synovitis and other objective signs of inflammation. I n only 3 of the 53 patients with rheumatoid arthritis did the urinary AMPS values disagree with this clinical assessment, whereas the erythrocyte sedimentation rate disagreed in 22 of the 53 cases. There appeared to be no influence upon the relevancy of AMPS values by the presence of subcutaneous rheumatoid nodules, anemia, abnormal serum protein electrophoresis, x-ray evidence of rheumatoid arthritis, the presence of rheumatoid factor or lupus erythematosus cells. This lack of influence appeared also to be true of associated conditions noted and certain drugs, including most of the usual anti-inflammatory drugs prescribed for rheumatoid arthritis. It is felt that this simple reproducible test of urinary AMPS excretion should be helpful to the clinician as an additional determinant of the presence of disease activity in patients with rheumatoid arthritis. .. DEFECTS IN AN ENZYME OF PURINE METABOLISM ASSOCIATED WITH EXCESSIVE PRODUCTION OF URICACIDIN GOUT William N . Kelley, Frederick M . Rosenbloom, J. Frank Henderson and J. Edwin Seegmiller, Bethesda, Md. Accelerated purine synthesis de novo with excessive uric acid production is a characteristic feature of a large segment of the gouty population. The greatest purine production and uric acid excretion is found in patients with the familial syndrome characterized by hyperuricemia, choreoathetosis, compulsive self-mutilation, mental retardation, and spasticity, which was first described by Lesch and Nyhan. A deficit in an enzyme of purine metabolism, phosphoribosyltransferase hypoxanthine-guanine (HGPRT), was found in dialyzed lysates of erythrocytes, fibroblasts or leukocytes of 9 patients who had in common excessive production of uric acid. They segregate into 3 groups on the basis of neurological function and enzyme activity, using guanine as substrate. 1) Three brothers showing 0.6 to 0.8 per cent of normal activity had typical gouty arthritis with onset in adult life and no obvious neurological dysfunction. 2 ) Two brothers showing 0.5 per cent of normal activity showed a mild to moderate dysfunction of the spinocerebellar type. Both patients developed uric acid nephrolithiasis in childhood and one developed gout at age 13. 3 ) Four unrelated patients with the complete syndrome as described by Lesch and Nyhan showed a complete absence (<0.004 per cent of normal) of enzyme activity. The activity of a closely related enzyme, adenine phosphoribosyltransferase, was not diminished in these patients. The finding of normal HGPKT activity in 10 additional patients exhibiting excessive production of uric acid suggests 1) that the decrease in cnzyme activity observed is not a secondary phenomenon, and 2 ) that excessive production of uric acid represents the phenotypic expression of a heterogeneous group of genetic clisorders. FURTHER OBSERVATIONS ON SOURCE01- SYNOVIAL FLUIDENZYMES G. P. Kerby and S . M . Taylor, Durham, N. C. Synovial fluid enzymes have been re-explored for source. Lysosomal enzymes acid phosphatase ( AcP) and lysozyme (LZ), glycolytic enzymes lactic dehydrogenasc ( LDII ) and pyruvate kinase (PK), and potential muscle enzymes adenylic kinase ( AK) and ATP-crcatine transphorylase ( CPK ) were measured in promptly-separated, centrifuged, washed cellular sediment resuspended in buffer to original volume and sonicated ( I ) , in supernatant fluid (11), and in wliole sonicated fluid (111). Theoretically the sum of I plus I1 should equal 111. hleasured protein content of each fraction established the validity of this point in each fluid. Data were scattered. In the small number of oxalated fluids studied thus far, enzyme activity and levels of protein, leukocytes and erythrocytes were greater in rheumatoids ( R A ) than in non- 291 ABSTRACTS rheumatoids ( N ) . Protein increase was overwhelmingly predominant in 11, indicating probable plasma and cellular enzyme leakage. AcP activity increased predominantly in I, indicating little lysosomal cellular leakage prior to sonication. LZ activity in contrast increased about equally in I and 11, indicating also a plasma or perhaps connective tissue source, since AcP increase did not suggest major intra-articular lysosomal release from cells. LDH and PK increased variably in I and 11, indicating possible multiple source and certainly significant cellular source. AK increased more in I than in 11, again indicating cellular source, quite possibly platelets, with some cellular and possibly connective tissue leakage. CPK increase, like that of LZ, was about equal in I and 11, again suggesting possible connective tissue leakage in addition to possible other source. Levels of LZ and CPK activity in both RA and N fluids and of LDH in RA fluids were lesy in I11 than in I plus 11, suggesting presence of an inhibitor effective on release of these enzymes into the fluid. IN SALIVA OF RHEUMATOID AND NON-RHEUMATOID INDIVIDUALS KALLIKREINS G. P. Kerby and S. M . Taylor, Durham, N. C. Kallikrein levels in human saliva have been determined in rheumatoid and non-rheumatoid individuals. Saliva was selected because it is secreted by a tissue usually not overtly inflamed in rheumatoid disease. All saliva samples were frozen 1 to 5 days before use. The enzyme was then partially purified by initial acetone precipitation at pH 6.0, absorption of the crude acetone powder in water on Cellex D at pH 7.0, elution, dialysis and concentration of the sample. In vitro assay used TAME as substrate. Esterase activity was not inhibited by soybean trypsin inhibitor, in contrast to trypsin which was used as a control. In a few random samples tested, biological activity ( increased blood flow and decreased blood pressure in a dog) was confirmed. Esterase activity is expressed as units ( E U ) equal to 1 FU for a preparation of human urinary kallikrein ( 5.7 FU/mg ) kindIy furnished by Web- ster. Results are given as E U per 100 mg. protein in the original saliva. The kallikrein content in saliva from non-rheumatoid controls averaged 194 ? 87 (S.D.) EU per 100 mg. in 10 individuals assayed to the time of this abstract. A single individual averaged 193 ? 18 EU per 100 mg in 9 samples prepared after saliva collected on different days was frozen for 1 to 10 days. In 15 rheumatoid patients assayed thus far, kallikrein content averaged 283 2 117 E U per 100 mg. The difference between rheumatoid and non-rheumatoid levels is not significant to date ( t = 2.00, p 0.05). Of interest was the demonstration of a positive rheumatoid latex agglutination with some samples, using commercial slide reagents. Positivity was not limited to samples derived from rheumatoid patients. This finding is being explored further. > IDENTIFICATION OF COLLAGEN IN SYNOVIAL FLUID Rodanthi Kitridou, Darwin J. Prockop and Daniel J. McCarty, Jr., Philadelphia, Pa. Phase contrast microscopic examination of wet smears of synovial fluid aspirated from arthritic joints frequently shows fibrous structures. These vary greatly in number and in length and their presence does not appear to correlate with a particular type of arthritis. Buttons of particulate matter obtained by centrifugation of synovial fluid samples which had been treated by freeze-thawing and with hyaluronidase were washed with distilled water and dried over anhydrous calcium chloride. The dry weight, hydroxyproline content ( after acid hydrolysis ), and alpha amino nitrogen content (Ninhydrin) of each sample were determined. Thirteen of 15 samples from 11 patients with a variety of joint diseases contained significant amounts of hydroxyproline. The collagen content of each sample based on dry weight ranged from 0.14 to 4.0 per cent with an average of 1.7 per cent. The collagen content based on the alpha amino containing nitrogen fraction ranged from 0.5 to 8.0 per cent. Articular cartilage obtained at necropsy, homogenized and treated like the joint fluid samples, contained 80 per cent collagen based on dry weight. Electron microscopic examination of two synovial fluid buttons and of the articular cartilage material showed typical collagen fibers with a periodicity of 640 A. The total collagen content of the joint fluid correlated poorly with the number of fibrils in the wet preparations as estimated by phase microscopy. A tentative correlation with joint instability was evident in this preliminary study. 292 ABSTRAmS COMPARATNE EFFECTSOF SCURVY AND PENIC~LLAMINE ON THE CONSERVATNE REUTILIZATIONOF MAH3-COLLAGEN IN VIVO LeRoy Klein and Bhagwan D. Garg, Cleveland, Ohio We have shown in chronically labeled animals that a significant amount of radioactive collagen can accumulate in granulation tissue that was newly induced by polyvinyl sponges or carrageenin. This suggested that mature collagen could be depolymerized to a soluble state and reaggregated during new collagen formation, The suggestion was tested in previously labeled animals by comparing the effects of scurvy ( a condition that decreases neutral-salt-soluble collagens) and penicillamine treatment ( one that increases neutral-salt-soluble collagens) on the specific radioactivities of soluble collagens. Ten young female guinea pigs and twelve weanling male rats were injected (8 to 10 times) with H3-proline over 4 to 5 weeks. Two months after labeling, guinea pigs were placed on scorbutic diets for 21 days and rats were fed 60 to 100 mgs of D-penicillamine per day for 8 to 15 days. Neutral-salt-soluble collagens ( 0.15 and 0.45 M NaCl) and citrate-soluble collagen were extracted from 5 gms of skin. The hydroxyproline from the extracted and insoluble collagens was separated chromatographically and their specific activities were compared. In the scorbutic state the amount of neutral-salt-soluble collagens decreased 75-85 per cent while in penicillaminetreated rats it increased 7 to 8 times over the control values. There were small increases of citrate-soluble collagen under both conditions. In the scorbutic state the relative specific activities of hydroxyproline from neutral-salt-soluble collagens were 3 to 4 times higher than the controls and almost equal to that of citrate-soluble collagen. No difference in the relative specific activities of neutral-salt-soluble collagens was observed in the penicillamine-treated rats. The relative specific activities of citrate-soluble collagen was slightly higher than the controls under both experimental conditions and was 75 per cent of that in the residual insoluble collagen. The higher specific activities of hydroxyproline in neutral-salt-soluble collagens from scorbutic guinea pigs and the lack of change of specific activities in neutral-salt-soluble collagens from penicillamine-treated rats support our earlier postulate for a conservative reutilization of fibrous collagen. EFFECTOF JWENILE RHEUMATOID A R ~ R ~ON ~ IDENTAL S MATURITY AND DEVELOPMENT OF THE DENTO-FACIAL COMPLEX R. N . Kramer, D . F. Bowers, T . R. Frye and W. M . Gibson, Columbus, Ohio Reported studies on mandibular growth in juvenile rheumatoid arthritis have been based on small numbers of children with obvious destruction of the temperomandibular joint. Arthritic involvement leading to destruction of the growth center and the impact of systemic illness on growth both need to be assessed. As part of a longitudinal study on 60 children with juvenile rheumatoid arthritis, measurements have been carried out to determine dental age in relation to chronologic age. A comparison has been made of dental maturity, bone age at the wrist and hand, and height and weight, in identifying the effect of this illness on somatic age. Lateral cephalometric roentgenograms have been traced and measured to show serial evidence of growth patterns of the dento-facial complex. Study casts have been made on 20 children for evahation of occlusion. Documentation has been made of the degree and duration of activity of the disease as well as the dose and duration of steroids where it has been used. The results of these measurements are compared with normals and demonstrate the effect of this chronic disease on dental maturity, mandibular outline, and occlusal relationships. INTRA-ARTICULAR TREATMENT OF RHEUMATOID ARTHRITISWITH GOLD, AND LIWCAINEHYDROCHLORIDE TRIAMCINOLONE, Wm. C . Kuzell, Donald L . Bittner, Lydia M . Seebach and Richard P . Glouer, San Francisco, Calif. Gold sodium thiomalate, triamcinolone, and lidocaine hydrochloride have been used in combination for the intra-articular injection of joints in 30 patients with rheumatoid arthritis. Injections have been given into the small joints of the hands and wrists as well as into the knees, ankles, elbows, 293 ABSTRACTS and shoulders. The study includes patients who have previously received gold intramuscularly as well as others who have only received intra-articular injections. Generally, it has been possible to discontinue intramuscular injections during the treatment with intra-articular injections. The duration of treatment has varied between 2 and 10 months. The response to treatment has been uniformly good both with respect to marked improvement in the joints injected and in the general status of the patients. Cytological studies of the joint fluids prior to and during treatment have demonstrated striking diminution in cell counts, and there has been an increase in viscosity of the synovial fluid coincident with improvement. Reactions to treatment have been minimal as well as infrequent and have not necessitated termination of treatment. The results of this study suggest that in chrysotherapy of “new” patients with rheumatoid arthritis the intraarticular rather than the intramuscular route of administration be tried. REMISSIONS IN RHEUMATOID ARTHRITISWITH A VARIETYOF SKININFLAMMATIONS John Lansbury, Philadelphia, Pa. We have observed 10 striking remissions in rheumatoid arthritis following various quite unrelated types of skin infl,ammation. The remissions lasted from 1 to 18 or more months (average 6 months). The degree of benefit was unrelated to the cause of the inflammation. The remissions were complete or excellent in 9 instances and gratifying in the remaining case. Causes of the acute dermatitis were: scalding of skin, moderately severe sunburn, ivy poisoning, contact dermatitis, two cases of seborrheic dermatitis, drug reactions to Atabrine and Camoquin, and two cases of gold dermatitis. STUDIESON THE The variety of unrelated inciting agents suggests that the benefit may be due to a common mechanism which is simply skin inflammation, irrespective of cause. Both the beneficial effect of heat and the deleterious effect of chilling might be similarly mediated, also the ancient and unconfirmed reports of benefit from skin blistering. These observations are only suggestive as they were not controlled. Nevertheless, like the earlier observations of the beneficial effects of pregnancy and jaundice, they point to a neglected area of investigation. SPECIFICITY OF ERYTHROCYTE AUTOANTIBODIES IN MAN John P . Lacldy and Richard F. Bakemeier, Rochester, N. Y. The autologous proteins sensitizing human RBC and causing positive direct Coombs tests ( D C T ) fall into three patterns: a ) yG-globulin alone; b ) yG-globulin plus complement ( C ) ; c ) C‘ alone. From the work of others some RBC autoantibodies show specificity for Rh or other blood group antigens. We now wish to report evidence for a correlation of DCT pattern with autoantibody specificity. Eluted yG autoantibodies from 31 patients (patterns a and b ) were tested against Rh..11 RBC, i.e., human RBC lacking detectable Rh antigens but possessing a normal representation of other known RBC antigens. In 11 of 17 cases with positive DCT of pattern a), autoantibodies failed to react with Rh,,,, RBC wbile reacting strongly with RBC of various “normal” phenotypes. Conversely, in 13 of 14 cases with positive DCT of pattern b ) , autoantibodies reacted equally well with Rh and “normal” RBC. These results suggest that: 1) yG autoantibodies with potential for C’ fixation are generally reactive with RBC antigens outside the Rh system, in keeping with experience with blood group isoantibodies; 2 ) that non-C‘-fixing yG autoantibodies may be divided into a major group which has specificity for antigen(s) of the Rh complex, and a smaller group which does not. In further studies, autoantibodies isolated from seven patients’ RBC during active disease reacted strongly with autologous Coombs-negative RBC obtained during remission. Thus, transition from active autoantibody formation to remission was not associated with a serologically detectable change in the RBC antigens involved. To test the idea that autoantibodies might arise against antigens that develop late in ontogeny, autoantibody eluates were tested against human fetal RBC of 10 to 14 weeks of age. Reactions were comparable, however, to those with adult RBC. Finally, a test was made of the hypothesis that RBC autoantibodies might arise from a maternal lymphoid graft reacting against paternally inherited antigens on the patient’s RBC. Such a maternal graft might be expected to be tolerant of maternal RBC antigens. However, the autoantibodies of 6 patients reacted vigorously with RBC from their mothers. 294 ABSTRACTS JAUNDICE WITH THE USE OF ~-HYDROXYPYRAZOLO( 3,4-D)PYRIMIDINE( 4-HPP) Martin D. Lidsky and John T. Sharp, Houston, Tex. 4-HPP has been given to 14 patients with primary gout, selected because of the presence of renal impairment and/or severe arthritis. Daily doses of 300 to 900 mg. were employed. The endogenous creatinine clearance ranged from 32 to 64 ml./min. in 6 of the 7 patients with renal impairment. Two patients with renal impairment developed intrahepatic obstructive jaundice and another developed elevation of serum alkaline phospbatase and transaminase activities without jaundice. In 2 other patients with renal disease, only the serum alkaline phosphatase activity became elevated. The 2 patients with jaundice received 600 and 900 mg 4-HPP daily for 3 weeks and had initial creatinine clearances of 32 and 52 ml./min. respectively. Liver dysfunction disappeared after 4-HPP was discontinued. Examination of liver tissue from one patient disclosed periportal in- flammatory infiltrates containing eosinophils. Readministration of 4-HPP to this patient 2 years after the episode of jaundice, when the creatinine clearance had fallen to 20 ml./min. did not produce liver dysfunction. The dose (300 m g ) was half that previously used. Six of 7 patients without renal impairment have been followed for 2 to 30 months. Elevation of serum alkaline phosphatase and transaminase activities has occured in one patient with an initial creatinine clearance of 96 ml./min. on a daily dose of 400 mg. The data suggest an increased susceptibility of patients with renal insufficiency to the hepatotoxic effect of 4-HPP. In such patients, the dose must be carefully monitored to achieve desirable reduction of serum urate concentration without inducing serious liver dysfunction. PERCUTANEOUS BIOPSY INTRA-ARTICULAR STRUCTURES UNDER D~RECT VISION ARTHROSCOPY: EXPERIENCE WITH OF Richard L. Lipson, Jackson J . Clemmons and John W. Frymoyer, Burlington, Vermont Marked variations in the histopathologic appearance of synovial tissue taken from different areas of the same joint have been well-documented. Because of the patchy distribution of the pathologic lesions, synovial membrane biopsies are usually done by open exploration or by percutaneous needle biopsy with multiple blind samplings. Several instruments and techniques have been devised to improve the yield obtained by percutaneous biopsy, but the incidence of failure to obtain adequate tissue for histologic evaluation continues to vary from 5 to 23 per cent. .An arthroscope that permits percutaneous biopsy under direct vision has been reported previously. It is the purpose of this report to relate our experience with this biopsy technique in 17 patients. Adequate synovial tissue was obtained for histologic examination in 100 per cent of the cases. The biopsy site could be picked at will and photographs obtained of the tissue to be biopsied. In addition, biopsies of articular cartilage, pannus, erosions and joint mice were obtained. The technique will be described and in vivo photographs of the tissue selected for biopsy as well as photomicrographs of the specimens obtained will be shown. COMPARISON OF THE VAPOR PRESSURE AND CRYOSCOPIC METHODS FOR DETERMINING THE TOTAL OSMOTIC PRESSURES OF SYNOVIAL FLUIDAND PLASMA Richard L. Lipson and A. Frances Johnson, Burlington, Vermont Accurate measurements of the total osmotic pressures of synovial fluid and plasma are of fundamental importance for understanding the pathophysiology of joint effusions. Most laboratories measure total osmolality of biological fluids by cryoscopic methods. In our laboratory, vapor pressure osmometry is used because it permits determinations under physiologic conditions, i.e., in an atmosphere of 5 per cent CO, at 37" C, and eliminates possible errors due to temperaturedependent molecular interactions and solute solubility. Cryoscopic measurements on synovial fluid present additional problems because of the effect viscosity has on heat conductivity and the foaming that frequently occurs during the procedure. Because of theoretical and practical problems inherent in the cryoscopic method, a study was 295 ABSTRACTS undertaken to compare the freezing point depression and vapor pressure methods. The total osmolality of 17 paired samples of synovial fluid and plasma from patients with various rheumatic diseases was measured by both methods. The results reveal that the total osmotic pressure of synovial fluid was always significantly higher when measured by freezing point depression than by the vapor pressure method with an average difference of 19 milliosmoles or 323 millimeters of mercury, and that of the plasma was higher by the freezing point method in all but one instance, with an average difference of 14 milliosmoles or 238 millimeters of mercury. Thus, our results indicate that a more accurate picture of in vivo osmolality of synovial fluid and plasma is obtained with the vapor pressure method rather than by freezing point depression. N-ACETYLCYSTEINE ( NAC ) THERAPY IN RHEUMATOID ARTHRITIS Arthur Lorber, Howard J . Weinberger and James Meriwether, Los Angeles, Calif. Thiols have theoretical therapeutic value in rheumatoid arthritis because they exert a protective antioxidant effect on sulfhydryl ( S H ) groups of enzymes, structural proteins, and depolymerize rheumatoid factor ( R F ) in vitro. Furthermore, the administration of thiols i.e., alpha-mercaptopropionyl glycine and d-penicillamine, has been reported to be beneficial in rheumatoid arthritis (RA). Our experience with d-penicillamine supports these observations. Nevertheless, occurrence of serious adverse reactions prompted us to investigate the therapeutic possibilities of another thiol compound, NAC. The medication was administered in doses of 2.5 to 4 grams daily. No serious adverse reactions were observed in 17 patients receiving oral and one intravenous NAC. Six patients with peripheral RA received the medication for nearly a year. Five showed improvement in grip strength; 4 showed reduced circumference of PIP joints, increased range of motion, and improved Steinbrocker functional index. Three patients with pulmonary involve- ment (biopsy-confirmed) manifested increased exercise tolerance and in 2 patients considerable resolution of radiographic pulmonary lesions. Four patients with extensive necrobiotic cutaneous lesions and evidence of visceral vasculitis manifested cutaneous healing and a halt in the progression of vascular lesions on therapy. S35-labeled NAC administered orally was excreted largely via the kidneys; some labeling of serum proteins and expectorated bronchial secretions was also observed. I n vitro incubation of rheumatoid sera with 0.025 molar NAC caused dissociation of IgM similar to that observed with other thiols. Decline in RF titer, however, was not achieved with NAC therapy though this has been observed with d-penicillamine. Serum protein SH content was noted to increase in several patients receiving NAC. Preliminary therapeutic evaluation of NAC in RA appears sufficiently encouraging to warrant further clinical and pharmacological studies of this agent and related thiol compounds. AND ASEPTICNECROSISOF GOUT, HYPERURICEMIA THE FEMORAL HEAD Donald E. McCollum, Robert S. Mathews and Phillip T . Pickett, Durham, N.C. In a group of 152 patients with aseptic necrosis of the femoral head, the authors found significant trauma in 62, sickle cell trait or disease in 18, and other diseases known to be associated with aseptic necrosis in 7 patients. In the remaining 65 patients no etiology could be established, and they were considered to be idiopathic. In the idiopathic group the average age of onset was 39 years, and in 34 per cent both hips were involved. Five patients had diabetes mellitus and 5 had significant hypertension. Twenty-six of 40 patients either had findings of cirrhosis or admitted excessive alcohol intake. At the time of reevaluation, 14 patients had developed definite gouty arthritis involving other joints. An additional 9 patients had hyperuricemia without gouty attacks. Routine study of synovium obtained at surgery revealed only nonspecific synovitis. When the synovium was fixed in absolute alcohol and examined using polarized light, we found uric acid crystals in the tissue of 3 patients with gout, three with hyperuricemia, and in m e patient who had aseptic necrosis without gout or hyperuricemia. Identity of the crystals was confirmed by use of a red compensating lens and methenamine silver stain. The x-ray changes in the hip of patients with gout and aseptic necrosis are similar to those produced by other diseases. The occurence of gout or hyperuricemia in 23 of 65 patients with idiopathic aseptic necrosis suggests that gout must be considered as an etiologic agent. 296 ABSTRACTS PRIMARILY NON-INFLAMMATORY ANKYLOSING ARTHRITISOF THE FINGERS Currier McEwen, New York, N. Y. It is generally believed that osteoarthritis does not lead to ankylosis. It is therefore considered to be of interest to report 4 examples of what apparently is straightforward, though severe, osteoarthritis of the hands which has progressed to solid bony fusion of distal ( D I P ) and proximal interphalangeal (PIP) joints of the fingers. In each patient Heberden’s nodes appeared first and early changes in PIP joints were typically those of osteoarthritis. The only other joints significantly involved were the first carpo-metacarpals in 2 of the patients. Although pain occurred in PIP joints, especially with change of weather, frank clinical evidence of inflammation was lacking and the erythrocyte sedimentation rate was little, if any, increased. Tests for rheumatoid factors were repeatedly negative. The sister of one patient had advanced osteoarthritis involving DIPS and PIPS with marked limitation of motion but without ankylosis. ANTI-INFLAMMATORY EFFECTOF Low DOSES COLCHICINE: IN A SENSITIVE BACTERIAL SYSTEM Stephen E. Malawista and Vincent T . Andriole, New Haven, Conn. Low doses of colchicine have not previously been thought to alter bacterial infections. However, because of various inhibitory effects on granulocytes, colchicine might be expected to have a general anti-inflammatory effect, which, in a bacterial system, would enhance the spread of infection. To test this hypothesis, we used a system sensitive enough to detect small differences in inflammation: the response of guinea pig skin to the intradermal injection of hemolytic, coagulase positive Staphylococcus aureus ( Giorgio). Bacteria ( 2 to 4 x 1 0 8 ) were placed at 0, 2, 4, 6 and 8 hours after single, intraperitoneal injections of saline or colchicine (13, 27 or 80pg/ 200 g ) . The mean diameters of erythema-induration and of necrosis were measured at 24 and 48 hours. Significant increases in erythema-induration andfor necrosis were seen with all the doses of colchicine used. The most prominent anti-inflammatory effects were found in the lesions placed from 4 to 8 hours after colchicine. These doses of colchicine did not produce neutropenia at 4, 8 or 24 hours. Although these results do not imply that small amounts of colchicine have any significant clinical effect in human infection, our findings do exemplify a general anti-inflammatory effect of colchicine, and tell us where to look next; namely, for the specific attribute( s ) of gouty inflammation that make colchicine clinically effective in acute gouty arthritis, but ineffective in most other inflammatory conditions. IN RHEUMATOID SYNOVIAL FLUID CRYOPRECIPITINS Robert L. Marcus and Alexander S . Totunes, Baltimore, Md. A previous report from our laboratory described the occurrence of anticomplementary activity in the synovial fluid of patients with rheumatoid arthritis. We have now found that this complement-fixing property of rheumatoid synovial fluid is invariably associated with the presence of cold precipitable proteins. To our knowledge cryoproteins in rheumatoid synovial fluid have not been previously reported. Cryoproteins have been found in 10 of 11 rheumatoid synovial fluids appropriately collected and processed at 37°C to prevent the loss of cryoprecipitins. Analysis of washed cryoprecipitates from these fluids indicate that they contained from 75 to 410 micrograms of cryoprecipitable protein per ml. Removal of cryoprecipitins by centrifugation after 18 hours of incubation at 0°C resulted in loss of all or a major portion of the original complement fixing activity of the synovial fluid, and this activity could he recovered in the precipitate. Further studies of these precipitates are in progress. Preliminary immuno-electrophoretic analysis with potent antihuman serum indicates the presence of several precipitin bands which include gamma G globulin in all, and gamma M globulin in some of the cryoprecipitates examined thus far. The association of cryoprecipitins with reduced complement levels and anticomplementary activity in rheumatoid synovial fluid is analogous to ABSTRACTS similar findings in the serum of patients with systemic lupus erythematosus previously reported by Christian and his coworkers. These findings support the hypothesis that aggregates (or com- plexes) containing immunoglobulin may be responsible for the anticomplementary activity and the reduced complement observed in rheumatoid synovial fluids. ON 34 CHRONIC ( HASHIMOTO’S ) SERIALCLINICAL-HISTOPATHOLOGIC OBSERVATIONS THYROIDITIS PATIENTS, WITH IMPLICATIONS CONCERNING THE PATHOGENESIS OF THIS LESION Alfonse T . Masi, William H . Hartmann, and Richard C . Reba, Baltimore, Md. The literature reviewed by Vickery and Hamlin (New Eng. J. Med. 264: 226, 1961) contains reports of 36 patients with Hashimoto’s thyroiditis who had multiple thyroid operations. We have observed 34 additional patients, including 9 with a thyroid operation antedating their first histopathologic diagnosis of thyroiditis. The patients were classified into three clinical categories: 1) thyrotoxic at any time, 2 ) euthyroid continuously, 3 ) hypothyroid without previous toxicity. The thyroid slides were reviewed ( W H H ) without knowledge of patient identity, clinical status, or sequence of thyroid operation, on 2 independent occasions one year apart. Reviewer variability as well as the evolution of the lesions were analyzed and clinical-histopathologic correlations were made. Eight patients who had clinical hyperthyroidism with epithelial hyperplasia typical of Graves’ disease at the first operation progressed to chronic thyroiditis with euthyroid or hypothyroid status. Seventeen patients who were initially euthyroid remained so with Hiirthle epithelial cells and prominent lymphocytes typical of Hashimoto’s thyroiditis at both operations. Nine patients with euthyroid-chronic thyroiditis progressed to hypothyroidism with epithelial atrophy and fibrosis. The most impressive histologic phenomenon observed between operations was a change in the thyroid epithelium. Hyperplasia, when prominent initially, was followed by the eosinophilic Hiirthle cell alteration and finally by atrophy. Round cell infiltration and germinal centers were seen mainly in the Hiirthle cell stage. These clinical-histopathologic observations and other recent data suggest that in Hashimoto’s thyroiditis the primary lesion is a chronic epithelial alteration allowing thyroglobulin to escape into the thyroid interstitium and draining lymph. The infiltration of lymphocytes with humoral antibody formation to thyroglobulin appear to follow a sustained release of thyroglobulin from colloid stores due to epithelial alteration. THE IMMUNOSEROLOGY OF RHEUMATOID ARTHRITIS(RA) R. S . Mathews, C . R. Lincoln and C . E. Buckley, KII, Durham, N. C. We did quantitative radial diffusion studies of immunoglobulin ( I g ) and ,GlC/plA concentrations, rheumatoid factor ( R F ) activity and antinuclear factor (ANF) in 56 patients with RA in comparison to 76 normal controls. We also examined synovial fluid (SF) in 24 patients and 9 non-rheumatoid patients and did simultaneous synovial biopsies. Statistical analyses of the percentile distribution of Ig concentrations in RA patients revealed a difference of -71 mg. (p<.5) For IgG at the 50th percentile, 84 mg (p<.Ol) for IgA and 153 mg (p<.OOl) for IgM. Ninetyfive per cent of RA patients had serum IgM concentrations above the 99.9 percentile of controls. The ratio of specific activity of RF (log titer/ [IgM]) in SF to serum ranged up to 4.8 in some patients. Differential counts of pyroninophilic plasma cells and lymphocytes were highest (86 per cent) in synovial biopsies of patients with high synovial fluid RF titers. IgM concentration and RF specific activity ratio paralled the activity of rheumatoid joint disease and was highest in patients with thickened proliferative synovia. All ANF assays were negative. The concentration of synovial fluid plC/plA was inversely related to the serum concentration and decreased in active rheumatoid disease. These studies document the kind of reactive hyperglobulinemia in RA and relate the local occurrence of RF and IgM in the joint to synovial pyronin positive mononuclear cells and ,81C/PlA depletion. 298 ABSTRACTS SYSTEMIC LUPUSERYTHEMATOSUS IN CHILDHOOD Aaron G. Meislin and Naomi Rothfield, New York, N.Y. Clinical and laboratory findings in 25 of 40 children with systemic lupus erythematosus have been analyzed to date and compared to the data from 200 adult patients with the disease. Of the 25 children with SLE thus far analyzed, the median age of onset was 11 years with 12 per cent at 3 years of age. The median age at diagnosis was 13 years. The diagnosis was not made in some patients until 8 to 11 years later, The most common symptoms prior to diagnosis were fever, joint pains and rash. Weakness was the principal complaint at time of diagnosis in 8 per cent and dramatic neurologic abnormalities in 8 per cent. The reticuloendothelial and hematopoetic systems were involved at the time of diagnosis in 56 per cent of patients and 48 per cent had renal involvement. At the present time 60 per cent of the patients are alive and 40 per cent have died. Of the 15 survivors, 3 are asymptomatic, 8 have minor symptoms and 4 are severely ill. The median survival time is 3 3/4 years from time of diagnosis and 7 years from the time of onset of symptoms. The median survival time in the 10 dead children was 1 1/2 years from the time of diagnosis and 3 years from the time of onset. The prognosis was directly related to the number of systems involved at the time of diagnosis. The incidence of renal disease and prognosis will be compared to the group of adult patients. The data suggest that although the disease is similar in children and adults, there is a longer period between onset of symptoms and time of diagnosis in the children. The delay in diagnosis may be related to the poorer prognosis in this group. The data also indicate that childhood lupus is not uncommon, since 20 per cent of 240 patients with SLE developed symptoms of their disease during childhood. THE RENALVASCULAR LESIONIN RHEUMATOID DISEASE James H . Meriwether, Jr., Howard J. Weinberger and Irene 0. Gleason, Los Angeles, Calif. Large autopsy series and 3 renal biopsy studies have not demonstrated arteritis in the rheumatoid kidney. Vascular lesions, when present, were those of arteriosclerosis and arteriolar nephrosclerosis. However, in those rheumatoids who develop the “malignant vascular syndrome,” renal lesions do occur and have been previously, sporadically reported. This renal vascular lesion has not been widely recognized, and this study reports an additional 8 such cases. Disseminated visceral vasculitis is unusual, occurring in 6 per cent of those patients with rheumatoid arthritis who came to autopsy at Wadsworth General Hospital, Los Angeles, from 1950-1965. Of the 11 patients who had evidence of active or chronic vasculitis in 3 or more visceral organs, 8 had renal arteritis. The lesions involved primarily the medium size (arcuate) to larger arteriolar vessels and varied in age from acute necrotizing injury to intimal scarring with organized thrombosis. Glomerular involvement was minimal, primarily mesangial thickening, with only one instance of diffuse glomerulonephritis. Tubular and interstitial changes were predominantly those of ischemic atrophy. The spectrum of vascular pathology is discussed and differences from other renal vascular diseases noted. The pathologic similarity to periarteritis nodosa is emphasized. Diffuse vasculitis was suspected in only 4 of the 8 cases premortem, confirmed by muscle biopsy in 3, and obtained several years before death in 2. There was minimal evidence of clinical renal disease and death was not attributable to renal involvement in any of the cases. Relevant clinical information including the incidence of hypertension and the use of steroids is included. PHYSIOLOGIC EFFECTSOF RHEUMATOID FACTORS: STUDIESOF PHAGOCYTOSIS IN SUBACUTE BACTERIAL ENJIIOCARDITIS R. P. Messner, T . Laxdal, P . G. Quie and R. C . Williams, Jr., Minneapolis, Minn. The physiologic consequences or in vivo effects of rheumatoid factors (RF ) remain controversial. Their possible role in the synovial inflammatory cycle or in competing with complement components, thereby sparing renal injury, has received recent attention. This study was directed at quan- ABSTRACTS titative in vitro estimation of the effect of both autologous and heterologous RF on phagocytic mechanisms using well-defined opsonins derived from patients with subacute bacterial endocarditis (SBE). A group of 32 patients with SBE were studied. In most instances highest opsonic activity for infecting bacteria occurred in 7s serum fractions isolated by gel filtration or gradient ultracentrifugations. 7s yG opsonins from DEAE cellulose chromatograms were added to human leukocytes in the presence of autologous or heterologous 19s RF. Titrations of both 7s opsonin and RF confirmed the sensitivity of phagocytosis assay, where end-point constituted killing of bacteria. Direct bacterial agglutination titers of SBE patient whole serum, 7 s yG, and combinations of 7 s yG with isolated rheumatoid factors indicated R F potentiation of agglutination in most instances. However, the results of such combinations on phagocytosis were more diverse. In one instance definite facilitation of phagocytosis was noted when heterologous R F was added to bacteria and 7s SBE patient opsonin. In others, no RF potentiation of phagocytosis was observed. In several experiments, various heterologous RF preparations showed almost complete inhibition of phagocytic effectiveness. Clearcut R F facilitation or inhibition of bacterial phagocytosis by human leukocytes varied depending on the combinations of 7 s opsonin and RF employed. COLLAGEN I N HUMAN ARTICULAR AND COSTAL CARTILAGE Edward 1. Miller, Jan K. van dm Korst and Leon Sokolof, Bethesda, Md. Disruption of collagen, the major protein constituent of articular cartilage, is an integral part of the osteoarthritic process. To determine whether alterations of collagen at the molecular level are associated with aging and/or osteoarthritis, costal and articular cartilage were studied in 25 necropsied individuals, 1 to 70 years of age. Collagen in both types of cartilage is insoluble in aqueous solvents which do not denature the protein. A denaturing solvent, such as 5 M guanidine hydrochloride ( 5 M G ) at neutral pH, is capable of solubilizing only 3 per cent of the total collagen in articular cartilage samples whereas somewhat less (about 1 per cent) of the collagen in costal cartilage is extractable. This was true for cartilage from infants as well as from aged individuals, suggesting that the collagen in these tissues is rapidly stabilized through the formation of intraand intermolecular crosslinks. The presence of gross osteoarthritic fibrillation had no effect upon the solubility of articular cartilage collagen in 5 MG. In all age groups, approximately 65 per cent of dried articular cartilage is protein, and collagen constitutes 90 per cent of the protein. Costal cartilage from patients in the first decade is similar to articular cartilage with regard to protein content and the proportion of collagen in the total protein. However, the proportion of collagen in the total protein of costal cartilage gradually decreases in older age groups, reaching a minimum value of 55 per cent in the seventh decade. Amino acid analyses of purified collagen from costal and articular cartilages indicate that it is aimilar to human skin collagen in amino acid composition, but contains more hydroxylysine and less lysine. HUMANANTIBODIES AGAINST ACETYLSALICYLIC ACID-ALTERED HUMANSERUMALBUMIN Percy Minden and Richard S. Farr, La Jolla, Calif. Normal human serum albumin (HSA) is altered following in vitro exposure to acetylsalicylic acid ( ASA ), as evidenced by an increased capacity to bind 1131-labeled sodium acetrizoate. Similar enhancement of the capacity of albumin to bind acetrizoate has been observed in patients with rheumatoid arthritis (RA) and has been induced in normal persons after prolonged oral ingestion of ASA. Sodium salicylate does not alter acetrizoate binding. To learn if the suggested structural change in ASA altered albumin (ASA-HSA) could be detected immunologically, rabbits were immunized with HSA or ASA-HSA in complete Freund's adjuvant. The capacities of these antisera to bind P I - H S A or 1131-HSA-ASA were studied by precipitating antigen-antibody complexes with 50 per cent saturated ammonium sulfate. No differences in the specificities of the antibodies produced against HSA or ASA-HSA were detected by means of either direct binding tests or by inhibition studies. However, since the rabbit immune mechanism sometimes fails to distinguish between subtle structural differences in human proteins such as the sub-groups of IgG, experiments were carried out to determine if the human immune mech- 300 ABSTRACXS anism could distinguish between these 2 antigens. Accordingly, radioimmunoelectrophoresis was employed in an attempt to detect antibodies against HSA and ASA-HSA in sera from patients with RA and aspirin disease and from normal human controls. Specific antibodies with capacity to bind ASA-HSA were present in the IgG fractions from all groups. Occasional sera also contained ASAHSA binding in IgA, and IgM. No anti-HSA was detected. I t remains to be determined if these frequently occurring antibodies against altered albumin may sometimes play a significant protective or pathogenic role in human disease states. POLYARTHRITIS AND ERYTHEMA-NODOSUM-LIKE LESIONSOCCURRING WITH SUBACUTE PANCREATITIS Gerald T. Mullins, ]r. and Ralph C. Williams, Jr., Minneapolis, Minn. During the past year, 2 patients have been encountered whose initial manifestations of illness included multiple pretibial erythema-nodosnm-like lesions. In one instance joint pain, stiffness, and multiple synovial effusions were also present. Only later did the presence of subacute pancreatitis become apparent. In one patient the initial clinical picture, skin lesions, and synovial swelling produced a tentative diagnosis of erythema nodosum alone. In both instances, the underlying pancreatic pathology was subacute obstructive pancreatitisin one case from a steering wheel injury and in the other pancreatitis secondary to cholelithiasis and common duct obstruction. Elevation of sedimentation rate, left pleural effusion, negative tests for rheumatoid factors, and gradual subsidence of nodular pretibial skin lesions were characteristic clinical features in both patients. Serum, ascitic, or urinary amylase and lipase values were markedly elevated during acute onset of skin lesions or synovitis. When obstructive pancreatic lesions were alleviated following definitive surgical therapy, prompt subsidence of both skin lesions and synovitis occurred. In both instances exploratory laparotomy showed massive focal peritoneal and omental fat necrosis. The skin and synovial space manifestations in such patients have generally been presumed to be due to generalized fat necrosis and peripheral effects of released circulating pancreatic enzymes. These cases are presented in detail as an unusual syndrome at times closely resembling erythema nodosum, but associated with severe, active pancreatitis. It now seems important to study intrinsic plasma or tissue proteolytic mechanisms in other patients with erythema nodosum of uncertain etiology. THEPROBLEM OF INFECTION IN SYSTEMICLUPUS ERYTHEMATOSUS Allen R. Myers, Iohn A. Milk and Marian W. Ropes, Boston, Mass. It is generally accepted that patients with systemic lupus erythematosus (SLE) are more susceptible to infectious complications than are healthy subjects or persons afflicted with a variety of other chronic diseases. Corticosteroid therapy is felt to be a major factor in predisposing such patients to infection. The frequency of infections in several reports of patients with SLE varies from 10 to 30 per cent. The relationship of infections to the course of the disease and in particular to the administration of corticosteroid therapy has not been previously studied in a large series of patients. The occurrence of a number of unexpected serious and even fatal systemic infections in patients with SLE prompted this study of our experience at the Massachusetts General Hospital. In a series of 89 patients with well-defined systemic lupus erythematosus, a total of 32 had one or more major infectious complications during the course of their disease. These infections have included salmonella, pneumococcal and meningococcal septicemias, pneumonia and a variety of localized septic processes. Nineteen of the 33 patients with infections had received steroid therapy for a total of 563 months. Infections were not a problem in 18 other patients who had received steroid therapy for 572 months. Urinary tract infections were also found in 36 of 82 patients who had urine cultures performed, approximately one half of whom had received steroid therapy. It is concluded that patients with SLE have an unusual incidence of infection, but that steroid therapy per se may not be a major factor in this respect. The relationship of infections to other features of SLE will be discussed. 301 ABSTRACTS RECOGNITION OF FEELING IN THE TREATMENT OF PSYCHOGENIC MUSCULAR RHEUMATISM W. Edward Naugler, San Francisco, Calif. There is a group of people with muscular “rheumatism” who tend not to recognize feeling as feeling but to project it (as a physical symptom) to a muscle group which has symbolic significance. Daily conversation attests to this universal, almost conscious equating of feeling and physical symptom, “This is going to be another headache,” “He is a pain in the neck,” “I feel pushed,” “Oh, my aching back,” etc.-these phrases refer to muscular response to an unpleasant feeling of which the person is not fully aware. If the physician considers that the symptoms are an expression of blocked awareness of feeling, then the clinical picture will be seen to have meaning. Three case presentations will be made. The case presentations illustrate that the patient actually has strong feelings which he is not fully aware of and that pain is often associated with sighing or a feeling of breathlessness at rest. Muscle spasm and areas tender to firm digital pressure are found on physical examination. Treatment is directed along the following lines: 1) Establishment of a good patient-physician relationship by allowing the patient to talk about what is most meaningful to him. When a relationship is thus established the patient’s feelings are more available to him and he feels safe in expressing them. 2 ) Teaching, if indicated, the technique of conscious breathing control when he feels emotionally uncomfortable. This is slow, quiet, abdominal breathing with the mouth closed. 3 ) Diazepam, 2.5-5.0 mg. 4 times daily. 4) Hot, moist packs followed by massage. 5 ) Injections of tender areas with xylocaine-steroid. DERMALATHYRISM: A DEFECTIN THE INTRAMOLECULAR AND INTERMOLECULAR CROSSLINKING OF COLLAGEN IN SOFT TISSUES CAUSEDBY PENICILLAMINE Marcel Nimni, Los Angeles, Calif. Administration of D-penicillamine to animals and humans causes a marked accumulation of soluble collagen in skin. Rats weighing 150 grams were given equimolar amounts of either D-penicillamine or BAPN fumarate (0.58 mM/day) for a period of 45 days. The penicillamine-treated animals grew as well as the controls and exhibited no visible abnormalities except for subcutaneous hemorrhages. The BAPN-treated showed a pronounced growth retardation and acute signs of osteolathyrism (thickening and deformation of the long bones, spinal curvature in the thoracic region, disruption of the epiphyseal plates ). Those receiving penicillamine did not show osseous changes but had about twice the amount of soluble collagen in their skin and tail tendon than the BAPN-treated and almost 8 times more than the controls. The tensile strength of the skin of the penicillamine animals was 15 per cent that of the controls. Shrinkage of the skin of BAPN rats occurred in the normal range (TS=63”C), but was undetectable in the penicillamine-treated. Crosslinking the penicillamine treated collagen with bifunctional aldehydes ( IO-3M) restored the T, to normal. Soluble collagen from the penicillamine and BATN- treated animals behaved normally ( thermal aggregation, viscosity, optical rotation). Penicillamine in the media ( lO-3M), or added after collagen gelation at 37°C caused the gel to dissolve rapidly upon cooling. Analysis of the collagen subunits in dermalathyrism induced by penicillamine ( 97% ) and those isolated from tissue collagen solubilized by thiols (66%8, 34 per cent p ) would seem to indicate that penicillamine disrupts and inhibits the formation of intermolecular bonds, and that the intramolecular defect described previously is a sequelae of the intermolecular abnormality. IN SKELETAL MUSCLEOF PATIENTS WITH SYSTEMIC MICROVASCULAR ABNORMALITIES LUPUSERYTHEMATOSUS Walter L . Norton, Eric Hurd, David Lewis and Morris Zi%,Dallas, Tex. Muscle biopsies have been performed in 22 patients with systemic lupus erythematosus (SLE ). Measurements of the frequency of blood vessels per cross sectional area, blood vessel diameter, and vascular basement membrane thickness were made by electron microscopic examination. The values differed from those in an equal number of clinically well subjects. Basement membrane thickness was also increased, though to a lesser degree, in groups of patients with rheumatoid arthritis and pulmonary tuberculosis ( 140 mp in both). The changes in blood vessel frequency and blood vessel diameter in SLE were similar to those previously noted in 302 ABSTRACTS Blood Vessels SLE Control per mm2 Blood Vessel Diameter (&) Basement Membrane Thickness (mp) 125 f 50 170 & 30 5.6 i 1.2 4.6 f 0.6 160 f 60 125 2 30 p<o.o1 p<o.o1 muscle biopsies of patients with scleroderma. Correlation with other parameters of SLE were sought. No correlation was found between vascular parameters and sex, age, race or duration of disease. Statistically significant relationships ( p <0.05) were found between blood vessel diameter and corticosteroid dosage, and between blood vessel diameter and serum gamma globulin concentration. Basement membrane thickness was found to be significantly smaller in patients receiving corticosteroids than in those not receiving steroid therapy (p<o.o1). Serum gamma globulin p<o.o5 concentration and steroid therapy were inversely related. The multiplicity of factors in these patients does not permit unambiguous conclusions, but the findings have been interpreted as evidence of significant peripheral microvascular injury in SLE. The relationship of microvascular abnormalities to serum gamma globulin concentration and the effect of steroid therapy on these abnormalities gives indirect support to a relationship between disease activity and the peripheral microvascular changes. CHANGES IN RHEUMATOIDFACTOR ACTIVITY DURING THE COURSE OF S ARCOIWSIS Irwin Oreskes and Louis Siltzbach, New York, N. Y. Rheumatoid factor (RF) has been found in patients with sarcoidosis in different investigations with varying frequency ranging from 10 per cent to as high as 47 per cent. I t is not clear whether these disparate results reflected technical variations in test procedures or differences in the patient populations studied. In the present study, among 64 patients with a tissue-confirmed diagnosis of sarcoidosis examined for RF in their serum, 38 per cent were positive on initial testing, with the tanned sheep cell test. Titers tended to be low with a median value of 1:80. By comparison, among 37 cases of definite or classical rheumatoid arthritis a median titer value of 1:5120 was found. The tanned sheep cell test proved to be considerably more sensitive than slide or tube latex tests in detecting RF activity in sarcoidosis. Presence of RF was unrelated to the presence or absence of joint symptoms. RF was far more prevalent in active disease processes than in inactive disease, and in patients with later stages of pulmonary involvement than with hilar node enlargement alone. Patients with RF were ill with sarcoidosis approximately twice as long as patients without RF. RF was found nearly twice as often in females as in males. Initial presence of R F was of little prognostic significance, but disappearance or reduction of RF titers upon later retesting was associated with an improving clinical course. Conversely, appearance of R F for the first time or increase in RF titer on retesting was associated with continued disease activity and with a relatively poorer clinical outcome. It appears that the finding of RF activity in sarcoidosis depends not only on the sensitivity of the test procedure employed, but on such factors as sex of the patients and the duration and severity of the disease. RHEUMATOIDDISEASEAND MALIGNANCY Duncan S. Owen, Jr., Marion Waller and Elam Toone, Richmond, Va. In view of the fact that rheumatoid disease is now considered by most observers to be a disturbance of the immune mechanism, it seems reasonable to direct some study toward the relationship between it and malignancy, which also may be related to disturbances of the immune mechanism. As a secondary consideration, it would seem of value to see if immuno-suppressive agents, particularly steroids, used often in the treatment of rheumatoid disease, would cause further change in the immune mechanism and increase the incidence of malignancy. In order to initiate this study, we have reviewed the charts of 196 patients with either 303 ABSTRACTS classic or definite rheumatoid disease and the charts of 125 patients with some type of arthritis other than rheumatoid-degenerative joint disease, gout, psoriatic arthritis, and tendinitis. The patients were all private, mainly Caucasian, in the middle or upper classes and were between 50 and 74 years of age. Each patient had a complete history and physical examination and those followed longer than one month had periodic complete examinations. The observation period ranged from 1 to 288 months with a mean of 49.5 months. The results were as follows: Nan-rheumatoid arthritis Total patients: 125 Malignancies : 5 1 colon carcinoma 1 renal carcinoma 1 prostatic carcinoma 1 breast & colon carcinoma 1chronic granulocytic leukemia Per cent malignancy: 4 Rheumatoid mthritis Total patients: 196 Malignancies : 8 2 breast carcinoma 1carcinoma urinary bladder 2 acute leukemia 1 carcinoma endometrium 2 carcinoma lung Per cent malignancy: 4.1 From the above data, it is concluded that there is no statistical difference in the incidence of malignancies in the two groups of patients. DERIVED FROM BACTERIAL CULTURES MYCOPLASMA ( P P L 0 ) - L m COLONIES Willy N . Puchas, Boston, Mass. Mycoplasma-like colonies apparently derived from bacterial cultures have been occasionally seen in this laboratory. More recently we have reported the isolation of PPLO-like colonies from a number of bacterial cultures-in 2 strains of salmonella, and in one each of diphtheroid and H. Influenza (Pachas and Dienes, 67th Meeting, American Society of Microbiology). The production of PPLO-like colonies was accomplished by exposing the bacteria to penicillin after they had been passed several times through cell-free tissue culture medium without antibiotics. Preliminary fermentation studies indicate differences between the 3 strains of PPLO-like colonies. The fermentation pattern was also different from that of the parent bacteria. Methylene Blue (0.002 per cent concentration) inhibited only the growth of the mycoplasma-like colonies derived from the salmonella. Antigenic studies are presently in progress and will b e reported later. The diphtheroid, strain NMI, produced 3 different bacterial phenotypes, each producing PPLO-like colonies. Reversion from the PPLOlike form to the diphtheroid was observed in one instance. Diphtheroids and PPLOs have long been considered to have a possible role in the pathogenesis of some rheumatic disorders. Recently others have reported the isolation of diphtheroids and PPLOs from rheumatoid and lupus materials. However, the origin of these isolates is still a controversial matter and awaits further evidence. The various microbiological findings, if genuine, may be due to differences in the cultural methods. On the other hand, if the diphtheroids are contaminants, their counterpart PPLO’s may be the result of their exposure to antibiotics. THEORETICAL CONSIDERATIONS CONCERNING THE ROLEO F RHEUMATOID FACTOR AND THE MACROPHAGE IN FIBROSING ALVEOLITIS H . Rowland Pearsall, Kenneth Ray Wilske and Edward H . Morgan, Seattle, Wash. There is an unexplained high incidence of fibrosing alveolitis (pulmonary fibrosis) in patients with rheumatoid arthritis (RA). This has been confirmed in our laboratory in a study of 108 patients selected solely on the basis of serum rheumatoid factor ( R F ) titer. Previous work (Caplan) has shown that there is an even higher incidence of this complication in patients exposed to silica particles. This paper will analyze the findings in our series of patients and review current theories concerning the pathophysiology of rheumatoid lung disease and silicosis. I t is proposed that the slowing of capillary circulation secondary to increased serum viscosity, known to occur in RA, favors the deposition in the lung of RF and other macroglobulins necessary for the formation of RA inclusion bodies. Subsequent phagocytosis of these inclusion bodies by lung macrophages results in fibrosis in a manner similar to that thought to occur in silicosis. 304 ABSTRACTS RENALEVALUATION IN DISCOIDLUPUSERYTHEMATOSUS (DLE ) T. I. Pekin, J . F. Maher, N . J . Zuaifler, T . Antonovich and P. N . Horvath, Washington, D.C. Many studies have tried to relate chronic DLE and systemic lupus erythematosus (SLE) but none have included systematic renal evaluation. This study was designed to determine if renal abnormalities occur in DLE and, if they are present, their relationship to other clinical or immunologic features of DLE. Twenty-one patients with typical skin lesions and biopsies were chosen by a dermatologist as examples of uncomplicated DLE. Their histories and physical examinations were evaluated for evidence of systemic diseases. Laboratory studies included L E cell preparation, sedimentation rate, globulin level, serum complement, rheumatoid factor, antinuclear, anticytoplasmic and anti-DNA antibodies. Renal studies showed proteinuria, present in half, exceeding 300 mg/day in 2. Urine sediment was abnormal in 6; none had blood casts. Creatinine clearance was low in 4 and PSP excretion decreased in one. Bacilluria was present in 2 and pyelography abnormal in 2 . Six had no clinical renal findings, 6 only trace proteinuria, and 4 multiple but minimal findings. Renal disease was strongly suspected in 5. Biopsy showed glomerular changes consistent with mild lupus nephritis in 5 and vascular lesions in 3 others. Renal abnormalities did not correlate with extrarenal laboratory findings. It is concluded that minor renal abnormalities occur frequently in DLE; therefore, SLE cannot be distinguished by renal evaluation. THESIGNIFICANCE OF IMMUNO-CONGLUTININ IN RHEUMATOID ARTHRITIS J. S . Percy, Denver, Colo. Immuno-conglutinin is an antibody to adsorbed complement, i.e., it is produced in man in response to the fixation of complement on an antigen/antibody complex. It is probable that the titer of immuno-conglutinin reflects the amount of complement fixed, and therefore the magnitude of the antigen/antibody reaction. In 100 patients with rheumatoid arthritis, the immuno-conglutinin titer has been shown to correlate directly with a clinical assessment of the degree of disease activity. Levels of this antibody have also been compared with the titer of rheumatoid factor, erythrocyte sedimentation rate, white cell count, hemoglobin and the course of the disease. Since it is conceivable that the results obtained in rheumatoid arthritis simply reflect non-specific tissue damage, conditions involving aseptic tissue necrosis [myocardial infarction ( 3 0 ) , closed fractures and dislocations ( 2 2 ) and uninfected skin abrasions (18)] were studied. The levels of immuno-conglutinin found in these conditions did not differ from those of the normal population. This work is thought to show that an etiologically significant antigen/antibody reaction, involving complement, occurs in rheumatoid arthritis. THEAPPEARANCE OF A LYSOSOME STABILIZER I N ADJUVANT ARTHRITIS THE COURSE OF Robert H . Persellin, Portland, Ore. There is substantial evidence relating lysosomes to the development of the inflammatory reaction. Once initiated, the inflammatory process would tend to be self-perpetuating, since lysosome contents are autolytic following release from the organelle. If substances capable of impeding this release appeared as a consequence of tissue degradation, they could interrupt the inflammatory process. Using adjuvant arthritis in rats as a model of self-limited inflammation, the occurrence of a lysosomal stabilizer was investigated. Sera obtained at various stages of polyarthritis were studied for their effect on the stability of a rat liver lysosome suspension, stressed by incubation at 37" C. Enzyme activities liberated into the supernate were assayed. The activities of 2 lyso- soma1 enzymes, acid phosphatase and /3-glucuronidase, released from the organelles in the presence of a 1 : l O dilution of arthritis serum, were 47 and 41 per cent of control values, respectively. A mitochondria1 enzyme, isocitric dehydrogenase, was not affected. Enzyme activities were not inhibited by arthritis sera. The lysosome-protecting effect reached a maximum soon after the peak of inflammation and was not detectable when the arthritis had completely subsided. The serum factor was not related to levels of circulating corticosteroids. Neither heating at 56" C., for 30 min., nor repeated absorption with antigen-antibody complexes altered the level of activity. The stabilizer was non-dialyzable, could be totally removed by absorption with washed lysosomal 305 ABSTRACTS membranes, but was not found in the gamma globulin fraction of serum. Activity appeared to be in the alpha-2 globulin fraction, suggesting the serum factor may be an acute-phase protein. I t is concluded that the membrane-reactive OSTEOARTHRITISOF THE lysosome stabilizer appearing in the course of adjuvant arthritis is a consequence of tissue destruction and may represent a homeostatic response to inflammation. FIRSTCARPOMETACARPAL JOINT I . B. Peter and Leonard Marmor, Los Angeles, Calif. Osteoarthritis of the first carpometacarpal (trapezio-metacarpal ) joint frequently accompanies Heberden’s and Bouchard’s nodes in postmenopausal women in whom there is no generalized osteoarthritis. Our recent experience shows a fema1e:male incidence of about 1 O : l . Careful clinical and roentgenographic examination typically shows the disease to be bilateral, but symptoms are sometimes unilateral. In this case, and especially when other joints are asymptomatic, the diagnosis may be confused with De Quervain’s disease or flexor tenosynovitis or the swelling at the thumb base may be mistaken for a ganglion. Rheumatoid arthritis commonly spares this joint unless wrist involvement is severe. Grasping, pinching and wringing movements cause pain which is especially severe with abduction of the metacarpal. Occasionally the origin of the pain may not be clear to the patient, or may seem to arise in the metacarpophalangeal joint, but crepitus and pain can be reproduced on rotation of the metacarpal with the wrist fixed. Because the base of the metacarpal tends to sublux proximally and radially, the hand assumes a “squared” appearance. X-rays show loss of joint space, osteophytes and sometimes para-articular ossicles and subluxation of the first metacarpal. An excellent view for demonstrating the entire trapezio-metacarpal joint is obtained by an A-P view of the hand and forearm in full internal rotation. Illustrative examples of this disease will be presented and its treatment discussed. THERAPY IN TWENTY-FIVE PATIENTS WITH RHEUMATOID ARTHRITIS ( RA ) AZATHIOPRINE VoZ K . Philips, W a l d a a r Bergen and Norman 0. Rothenich, Columbus, Ohio Nineteen patients with classical RA and 6 with definite RA were treated with azathioprine as primary or supporting treatment for periods of 3 to 4 months, interspersed with varying placebo trial periods. All patients, 22 of whom were female, had disease established for more than one year, and had proven unresponsive to adequate therapy including salicylates, steroids, gold, indomethacin or combinations of these. Clinical observation, made at 2- to 4-week intervals, consisted of the Systemic Index, the Articular Index of Lansbury, and questions concerning symptoms of drug toxicity. Hematologic and biologic evaluations included erythrocyte sedimentation rate, reticulocyte count, quantitative latex fixation test, and serum electrophoretic pattern. Anti-DNA titers were determined by bentonite flocculation, immunofluorescent study, and using 1131 tagged DNA antigen. Anti-RNA was detected by ,bentonite flocculation method. , Salicylate was usually maintained at a daily dosage of 2.4 to 3.6 grams per day. Attempts at reduction of steroid rarely exceeded 1 mg. prednisone or equivalent per day per visit. Where appropriate, gold therapy was discontinued. Although some patients reported subjective improvement, serial evaluation of Systemic Index remained essentially unchanged during the treatment. The Articular Index showed a definite decline in the number of joints actively involved in synovitis with relapse during placebo trials. Anti-RNA antibody was found present in 23. It was not altered by treatment. Anti-DNA antibody was found in only 5 patients’ serums by bentonite flocculation method, but in 15 by the immunofluorescent method. In no patient was the presence of anti-RNA or anti-DNA antibody altered by the dosage of azathioprine given (100150 mg./day). Neither the titer of rheumatoid factor (latex fixation), nor quantity of gamma globulin present in the sera of these patients were altered by azathioprine therapy. Toxicity was limited to some degree of anorexia or nausea in 22 of the 25 patients. Three patients demonstrated temporary granulocytopenia, disappearing on reduction or discontinuance of the drug, it being resumed in lower dosage without subsequent effect. Azathioprine may have mild anti-inflammatory effects rather than immunosuppressive effects in the dosages given. 306 ABSTRACTS THEANTINUCLEOLAR ANTIBODIES:CLINICALINCIDENCE, IMMUNOFLUORESCENCE PATTERNS AND A DESCRIPTIONOF A NEW ANTIBODY TO AN INTRANUCLEOLAR STRUCTURE R. F . Ritchie, Portland, Maine In conventional immunofluorescent techniques antinucleolar antibodies ( ANoA) are frequently masked by coexistent antinuclear antibodies (ANA). The clinical incidence and immunofluorescent morphology of this group of immunoglobulins was investigated by examination of Disease SLE ss liA JRA #Pts. #ANAS-> 1:16 55 22 184 49 53 17 58 11 % Total fluorescence photomicrographs ( 1250X ) produced by a method which yields sharp resolution. In the group of patients with definite rheumatic diseases the following distribution of ANA and ANoA were found: ANoA+ ( 96% ) 15 (77%) (31%) (22%) 9 Examination of ANoA immunofluorescent patterns indicates that, as also occurs with antinuclear antibodies, several types exist. Five fluorescence patterns have been observed: a ) the whole nucleolus, b ) a lobnlated intra-nucleolar structure which resembles the nucleolema, c ) very small, usually single, round intra-nuclear structures, d ) a rim of bright fluorescence around the nucleolus, e ) combinations of the above. The lobulated pattern ( b ) is most frequently observed. Using a fluorescein-labeled preparation of this yG antibody in the ANA inhibition technique previously described, the clinical incidence in 139 rheumatic sera was as shown in the table to the right. 14 4 % Total %ANA+ > 1 :I6 (27%) (41%) ( 8%) ( 8%) 28% 53% 24 % 36% Disease SLE ss RA JRA Total %+ 7% (4/55) 9% (2/22) 3% (5/184) 0 (0/49) 4% (11/309) The data indicate that antinucleolar antibodies are common in rheumatic patients-particularly those with systemic sclerosis. Identification of a new factor reacting with only a portion of the nucleolus, perhaps the nucleolema, is further evidence for the fine specificity of these antibodies. FUNCTION IN THE SURGICAL RHEUMATOID HAND H . S . Robinson, Patricia MacBain and F. P. Patterson, Vancouver, British Columbia A prospective study of hand function following a uniform surgical procedure on the rheumatoid hand has been carried out. The surgical procedure consisted of metacarpophalangeal ( M P ) joint arthroplasty ( M P head resection), realignment of fingers with Kirschner wires and reposition of extensor tendons on the radial side. The procedure was carried out by a single surgical team in the Department of Orthopaedic Surgery at the University of British Columbia. Patients selected had severe MP joint involvement with subluxation and associated ulnar drift. All had extensor tendon displacement. Care was taken to screen out those with marked proximal interphalangeal joint limitation. Hand function tests measuring some aspects of function have been established, including stand- ardized tests of power grip; applied strength; dexterity; pinch strength; and hook strength. These were carried out in the Canadian Arthritis and Rheumatism Society Arthritis Unit in Vancouver. The present study is concerned with 14 hands in 12 consecutive patients who have been followed from 6 months to 1 year post-operatively by a team consisting of surgeon, occupational therapist and rheumatologist. In this group of patients the battery of functional tests were applied preoperatively and post-operatively at 6-month and 1-year intervals. I n the overall picture 8 of 14 hands have significantly improved function, 4 are unchanged functionally, and 2 are worse. One of the latter developed a complicating infection. Improvement occurred in the majority of cases 307 ABSTRACTS in the areas of pinch strength, dexterity and hook strength with lesser gains in power grip and its application. With one exception, realignment of the fingers has been maintained. From the patients’ point of view, there has been less pain, improved function and a desirable cosmetic result. FAMILIAL NEPHROPATHY AND GOUT IN A KINDRED Frederick M . Rosenbloom, William N . Kelley, Albert A. Carr and J . Edwin Seegmiller, Bethesda, Md. The renal disease associated with gout is clas- Among 4 sons of 2 affected fathers, the oldest 3 (ages 14, 16 and 17) have hyperuricemia and sically of late onset; morbidity is low and early mortality is rare. The presence of gout and renal diminished inulin clearances. The eldest has had disease with early death in 4 brothers stimulated one attack of gout. Audiograms on all are normal. investigation of 3 generations of their kindred. In Evaluation of uric acid metabolism by balance the first generation 3 brothers died with renal and isotope techniques revealed normal production. Renal biopsies on 2 showed no distinctive disease and gout before age 37. Another brother died at age 60; his serum uric acid was normal. pathology. Karyotypes on 2 were unremarkable. The high concordance of gout and renal disease An only sister has asymptomatic hyperuricemia. In the second generation, 4 sons of an affected in this family suggests that the 2 conditions are brother developed gout around age 20 and died both manifestations of the same genetic defect. with renal disease before age 35. Two other sons The transmission from father to son over 3 generain this sibship have normal serum uric acid. The tions is compatible with an autosomal dominant only son of a second affected brother has asymp- form of inheritance. Clinical and pathologic featomatic hyperuricemia. We have studied 9 of 13 tures of this disease distinguish it from previously members of the third generation. Three sons of described forms of hereditary nephritis. unaffected fathers have normal serum uric acid. IN RESPONSE TO ALLOPURINOL AN ENZYMATIC BIOCHEMICAL BASISFOR VARIATION Frederick M . Rosenbloom, William N . Kelley, John M . Miller and J. Edwin Seegmiller Bethesda, Md. Treatment with allopurinol produces interruption of uric acid formation by inhibition of xanthine oxidase, and inhibition of total purine production. Although the first effect is consistently observed in all patients, the magnitude of the latter varies greatly among individuals. A group of 5 patients with nontophaceous gout showed a decrease in total purine excretion (-19 to -75 per cent) when treated with allopurinol, while 8 additional patients showed no significant decrease (-8per cent to +23 per cent). A marked deficiency of the enzyme hypoxanthineguanine phosphoribosyltransferase (HGPRT) was found in 7 of these 8 patients who failed to show a response. The enzyme activity in dialyzed erythrocyte lysates, using hypoxanthine as a substrate, was <0.02 per cent of normal in 2 children with the familial neurological syndrome described by Lesch and Nyhan, 2 per cent of normal in 3 brothers with adult gout, and 1 0 per cent of normal in 2 brothers in a different family, one of whom had gout. Since the enzyme HGPRT is responsible for the conversion of hypoxanthine, guanine, or allopurinol to their respective nucleotides, the forms necessary for their actions as feedback inhibitors of purine synthesis, the observed deficiency readily explains the failure of allopurinol to reduce total purine excretion in this group. HGPRT deficiency was associated with a 5-fold increase over normal in cerebrospinal fluid oxypurine concentrations. This was further increased 2- to 3-fold by treatment with allopurinol. The possible role of oxypurines in the generation of the neurological dysfunction found in some of these patients will be discussed. INWMETHACIN IN THE TREATMENT OF JUVENILE RHEUMATOID ARTHRITIS Sanford H . Roth and DeWitt W . Englund, Phoenix, Ariz. Indomethacin has enjoyed widespread clinical usage as an anti-rheumatic drug. To date, how- ever, reported data has been insufficient to allow its application on other than an investigative 308 ABSTRACTS basis in the treatment of juvenile rheumatoid arthritis. This report concludes a four-year study of indomethacin in the treatment of 24 patients seen at the Phoenix Arthritis Center with the diagnosis of juvenile rheumatoid arthritis. The ages of the patients ranged from 3 to 15 years. Dosages of indomethacin were from 12.5 to 100 mgms. per day, depending on the surface area of the child. By A.R.A. Therapeutic Criteria, 9 of the 24 patients showed Grade I improvement, 9 showed Grade I1 improvement, and 6 showed Grade I11 improvement. In all instances there was improvement when indomethacin was added to the patient’s existing therapeutic regimen. In 5 of the above cases, however, a subsequent recrudescence of disease activity necessitated addition of other antiphlogistic medications. Side effects were minor although not uncommon and ranged from headaches to mild vertigo and nausea. An exception to this was one patient who developed an active duodenal ulcer necessitating the withdrawal of indomethacin and her other antiphlogistic drugs. I n this study, all 24 children demonstrated some degree of salutory effect from indomethacin. The drug was found to be relatively safe with the exception of one child who developed duodenal ulcer. I t is our conclusion that indomethacin has merit in the treatment of juvenile rheumatoid arthritis when used with proper care and caution in the overall management of the patient. THE USE OF PLASMAGOLDLEVELSIN DETERMINING DOSE, FREQUENCY, TYPEOF COLD SALT,AND IMPENDING TOXICITY IN CHRYSOTHERAPY FOR RHEUMATOID ARTHRITIS Norman 0. Rothermich, Wuldemar Bergen and Vol I<. Philips, Columbus, Ohio Freyberg’s findings ( 1941 ), that the concentration of gold in plasma reaches a maximum within one hour after injection, remains constant for a few hours and then declines, is reconfirmed. Soluble gold salts injected at 7-day intervals ( 2 5 mg. elemental gold) result usually in stairstep increases in the average plasma gold level to 400 mcg% ( & 100 mcg.% ). Increasing the frequency of gold injections to twice a week results in a more rapid rise in average plasma gold level, without a resultant increase in urinary excretion rate. Reduction of the frequency of injection of intramuscular gold to 2- or 3-week intervals results in a negligible plasma gold level, no incremental increase being noted upon each subsequent injection. Doubling the dose ( 50 mg. of elemental gold ), but not the frequency of gold injection doubles the average plasma gold level. Decrease of frequency of such gold injections to 2- to 3- week intervals results in negligible plasma gold levels. After initial 20-week “classical” soluble-salt chrysotherapy, attempted “maintenance” at 2, 3, and 4 week intervals results in rapid decline in average plasma gold levels, regardless of the dosage. If initial treatment with soluble gold salt is supplanted by “maintenance” with an oil-depot preparation, this decline may be avoided. Our early studies would indicate that measurement of plasma gold values and individualization of intramuscular gold injection frequency, dosage and type may be valuable in achieving maximum results from chrysotherapy. Our early studies ( 3 instances ) would indicate no definite relationship between average plasma gold level achieved or maintained and the appearance of muco-cutaneous lesions of gold toxicity. SERUMANTINUCLEAR FACTORS I N PROGRESSIVE SYSTEMIC SCLEROSIS ( SCLERODERMA ) Naomi F . Rothfield and Gerald P . Rodnan, New York, N. Y. and Pittsburgh, Pa. The sera of 48 patients with progressive systemic sclerosis were studied for antinuclear factors ( ANF) by the indirect fluorescent antibody technique, using mouse liver sections as a source of nuclei. Sera from 28 patients had a positive test for ANF at a titer of 1:16 or greater; 4 patients had titers of 1:256 or greater. The most common pattern of nuclear fluorescence observed, using undiluted sera, was that of fine speckles which formed a reticular network (14 patients.) Large discreet speckles were present in 13 sera. A dif- fuse pattern without speckles was present in only 2 sera. The peripheral pattern was not observed. There was no correlation between rapidity of progression of disease or disease duration and titer or pattern of ANF. Of the 28 sera which gave a titer of 1:16 or more using antihuman y-globulin, 18 had both IgM and IgG ANF, when specific anti-IgG and anti-IgM were used. Four patients had only IgM ANF and 6 patients had only IgG. The large speckles were most commonly seen using the anti-IgM. There was no correlation be- 309 ABSTRACTS tween the presence of IgM ANF and rheumatoid factor. There was no correlation between the presence of any immunoglobulin class of ANF and severity of disease progression or duration of disease. None of 84 first-degree relatives of 24 patients had a titer of greater than 1:8. Titers of 1:8 or less were present in 13 relatives. One of 18 spouses had a titer of 1:128. The data indicate that the ANF present in scleroderma patients occur less frequently, are of a lower titer and, in general, give a different pattern of nuclear fluorescence than the ANF in sera of patients with systemic lupus erythematosus. HEREDITARY PERIODIC EDEMA TREATED BY SYMPATHECTOMY Jerome Rotstein, Stanley C . Fell and Francis F. Foldes, Bronx, N. Y. A 17-year-old white woman presented with increasingly frequent episodes of intermittent elephantine non-pitting blanching erythematous edema of the right hand and left foot for 3% years and 25 years respectively. The only other physical abnormality was dermatographia and the only laboratory abnormality was a persistently elevated eosinophil count. Lymphangiograms of the lower extremities during periods of remission were normal. A diagnosis of juvenile rheumatoid arthritis was made by many observers prior to admission to our facility. The physical findings and laboratory abnormality suggested to us a disorder of the wheal-and-erythema type or triple response of Lewis reaction. This results from excessive sympathetic activity which leads to constriction of the post-capillary venule and precapillary arteriole, based on a disorder of histamine release or a defect in the z o n a l reflex. Sympathetic nerve blocks relieved pain completely and edema partially. A right transthoracic sympathectomy completely relieved the upper extremity edema in 72 hours, followed by the longest continuous remission in 3% years. A left lumbar sympathectomy produced even more dramatic relief of signs and symptoms in the lower extremity. A discussion of periodic edema and the rationale of therapy of this disorder will be pre. sented in this paper. EARLY SYNOVECTOMY IN THE JWENILERHEUMATOID ARTHRITIC John L . Sburburo, Jr., Albert0 Bosch, Peter Vunace and Evan Owens, Philadelphia, Pa. and Atlantic City, N. J. There have been only sporadic reports concerning the efficacy of early synovectomy in the rheumatoid arthritic child. Very little is known about the subsequent course of the disease or the local response of the surgically treated joint. Of great importance is the effect of synovectomy on the developing epiphysis. This report will describe our experience with early synovectomy in the systemic form of rheumatoid arthritis. Over the past two years, 10 patients have been treated with selective synovec- tomy. Where feasible, the opposite joint has been utilized as a clinical control. The ankles, knees, hips, wrists and finger joints have been evaluated with 15 surgical procedures. The average age was 9.7 years, with the youngest being 6 years and the oldest 17 years. This is an on-going project and it will not be possible to state any definite conclusions for a number of years; however, the early results have been quite encouraging. Our indications, contraindications and results thus far will be discussed. IN PATIENTSWITH GENERALIZED SCLERODERMA (PROGRESSIVE COLLAGENALTERATIONS ) TREATED WITH DIMETHYL SULFOXIDE ( DMSO ) SYSTEMIC SCLEROSIS Arthur L. Scherbel and Lawrence J . McCormack, Cleveland, Ohio The effect of dimethyl sulfoxide administered for 3 to 30 months to 61 patients with progressive systemic sclerosis is reported. Criteria for classification of disease severity and also for evaluating objective clinical improvement are included. Good to excellent cutaneous improvement occurred in 40 of the patients including the healing of ischemic ulcers in 30 of 33 patients. No significant effect was noted on visceral manifestations of the disease. During the study, 8 patients with advanced disease died of renal, cardiac or pulmonary complications. Histochemically, serial skin biopsies showed an increase in acid mucopolysaccharides and a decrease in collagen bundles. Simultaneously, urinary hydroxyproline levels increased. 310 ABSTRACTS Certain patients also shqwed a decrease in interstitial calcinosis. To our knowledge these changes GAMMAGLOBULIN TURNOVER have never been reported with other methods of therapy. IN RHEUMATOID ARTHRITIS Frank R. Schrnid, Chicago, Ill. Gamma globulin derived from healthy donors is metabolized normally in recipients with rheumatoid arthritis. The present study suggests that gamma globulin derived from patients with rheumatoid arthritis acts similarly when its turnover is determined in either rheumatoid or nonrheumatoid recipients. Gamma globulin from 7 individual donors was isolated from either whole serum or its ammonium sulfate fraction in the first elution peak off DEAE cellulose and trace-labeled with iodine-131. Each preparation usually was given to 2 or 3 recipients. In every case, one of the recipients was also the donor of the globulin. A total of 17 studies were performed in 12 subjects, including persons with hyper- and hypogammaglobulinemia and one with rheumatoid factor but without rheumatoid arthritis. Five subjects were studied twice. Serum and urine concentrations of the label were followed for usually 3 weeks. The data were calcnlated as described by Cohen and Freeman (Biochem. J. 76:475, 1960). No correlation could be established between the presence of rheumatoid factor and rate of removal of the label as determined by the fractional catabolic rate or serum half life. However, a correlation was found between the total intravascular pool of gamma globulin and its rate of removal, hypergammaglobulinemia being associated with accelerated removal and hypogammaglobulinemia with decreased removal. Four of the globulin preparations were partially denatured as indicated by reduced half lives (Z = 11 days, normal 20 days) and by a faster catabolic rate early in each study. Although rheumatoid factor might have been expected to bind more effectively to such preparations and hasten its removal, no differences could be discerned between rheumatoid and non-rheumatoid recipients. These results suggest that the turnover of gamma globulin in the patient with rheumatoid arthritis is governed by the amount of globulin in the intravascular space as has been shown for normal individuals. Rheumatoid factor does not appear to influence this function. Its possible effect upon the elimination of aggregated globulin or globulin in immune complexes has not been excluded. THESYNOVIAL MEMBRANE IN PSEUDOGOUT: ELECTRON MICROSCOPIC OBSERVATIONS H . Ralph Schumacher, Boston, Mass. Many studies have reported joint fluid findings in pseudogout ( chondrocalcinosis articularis ) . Although the histopathology of the synovial membrane has been briefly described (McCarty and Gatter, Bull. Rheum. Dis. 14:331, 1964) its ultrastructure has not been investigated. Therefore, needle biopsies from knees of 2 patients during acute episodes of pseudogout were studied by light and electron microscopy. Calcium pyrophosphate crystals were found in the interstitium, in hyperplastic type A and B synovial lining cells, and in neutrophils and macrophages. They were rodlike, acicular, rhombic or irregular with a lacelike internal structure. The crystals were best retained in alcohol-fixed specimens, but these gave poor preservation of tissue ultrastructure. Frequently, after glutaraldehyde fixation for electron microscopy only electron-lucent crystal-shaped spaces remained. Intracellular crystals or residual clefts were gen- erally membrane-bounded and appeared to be in phagosomes which also contained fibrin and cellular debris. A number of crystals were located adjacent to the Golgi apparatus of type B lining cells. Many of these cells also contained focal lipid deposits. Phagocytosis of degenerating neutrophils by macrophages was common. Fibrin and extracellular dense bodies were seen in the interstitium. Many small venules demonstrated endothelial gaps, some of which were occupied by erythrocytes and emigrating neutrophils. Basement membranes were often laminated. Crystals were not found in the vascular wall, and there was no evidence of thrombosis or necrosis of blood vessels. The vascular changes were therefore considered compatible with the effects of a chemical mediator. These findings will be discussed and compared with ultrastructural studies in other joint diseases. 311 ABSTRACTS THEMICROVASCULATURE OF THE SYNOVIAL MEMBRANE: ULTRASTRUCTURE AND RESPONSE TO ISCHEMIA AND JOINT MOTION H . Ralph Schumacher and Guido Majno, Boston, Mass. Recently there have been several reports of ultrastructural alterations in the blood vessels in rheumatic diseases; however, there has been no systematic investigation of the fine structure of normal synovial vessels or of vessels responding to relatively simple forms of injury. Therefore, we have studied the synovial membrane of the Cebus Albifrons monkey by whole mounts and light and electron microscopy after intravenous injection of tracer particles (carbon, ferritin ) , Synovium was examined from 3 areas of the knee joint: capsule, fatty villi and fibrous synovium overlying the femoral condyles. Electron microscopy of normal superficial capillaries and venules showed many endothelial fenestrations closed by thin diaphragms. Deeper vessels had strikingly high endothelium with cytoplasm unusually rich in organelles including many pinocytic vesicles, dense bodies, fibrils, rod-like Weibel-Palade bodies, abundant rough endoplas- mic reticulum, and phagosomes containing lipid and other materials. Numerous pericytes were prominent even around the smallest vessels. Capillaries between lobules of fat consistently had thinner, darker endothelium. Tracers occasionally leaked through gaps between endothelial cells. In order to ascertain whether joint motion was responsible for these “physiologic leaks”, knees were subjected to passive flexion and extension for periods up to one and one half hours; in some animals significant increases in leakage were noted, but in others none were demonstrable. The basis for these discrepancies is under investigation. Two and one half hours of tourniquet-induced ischemia caused minor, focal increases in leakage, but no other morphologic lesions. These observations will be discussed in relation to the possible role of microvascular changes in joint disease. IMMUNOCHEMICAL OBSERVATIONS ON SERAOF PATIENTSWITH SYSTEMIC LUPUS AND DURINGCLINICALACTIVITY, AND IN REMISSION ERYTHEMATOSUS (SLE), PRECEDING Peter H . Schur and John Sandson, New York, N. Y. Serum antibodies to nuclear components and low levels of hemolytic complement (C’H50) are thought to occur primarily in patients with active rather than inactive SLE. Relatively few patients have been observed on whom similar studies were performed prior to the development of clinical activity. The present investigation was undertaken to determine what immunochemical parameters would correlate with or precede clinical activity. Ninety-two patients with definite SLE were studied. Most of the patients were seen during both clinically active and inactive phases. There was no difference in the incidence of antibodies to calf thymus, soluble nuclear antigen, or nucleoprotein ( N P ) in patients with active or inactive disease. Serum C‘H50 was normal at some time in only 10 per cent of patients with active renal disease, 50 per cent with inactive renal disease, and 88 per cent without renal disease. Serum C‘H50 was low at some time in over 90 per cent of all patients. Therefore a normal level of serum C‘H50 strongly argues against active renal disease. Similar analyses indicated that precipitating antibodies to ribosomes ( R b ) occurred only in renal disease and that precipitating antibodies to deoxyribonucleic acid (DNA) and heat-denatured DNA (HDNA) favored the presence of (active) renal disease. Some patients were seen in whom exacerbations were preceded by a fall in serum C’H50, others by a simultaneous fall in C’H50 and rise in antibody titers to NP and Rh. Of particular interest were a number of patients in whom exacerbation of disease was preceded by increasing titers of antibodies to DNA (and Rb), followed by hypocomplementemia. These studies suggest that therapy based on immuno-chemical parameters may be utilized in certain patients with SLE in order to prevent clinical exacerbation. ACIDOSISIN RHEUMATICDISEASES LATENTRENAL TUBULAR Martin A. Shewn, and Wu-Hao Tu, San Francisco, Calif. Because hyperchloremic acidosis with inadequate acidification of urine (renal tubular acidosis ) has been reported in hyperglobulinemic states, investigation of renal acidification in rheumatic diseases was undertaken with the purpose of detecting subclinical (latent) cases of renal tubular 312 ABSTRACTS acidosis. Ten patients with Sjogren’s syndrome ( S S ) , 12 with systemic lupus erythematosus (SLE), and 18 with rheumatoid arthritis (RA), were studied and compared to 21 healthy subjects. All patients had normal values for 24-hour endogenous creatinine clearance and serum electrolytes, and in each the urine was sterile. Renal acid excretion was assessed before and after administration of an acute acid load (0.1G. NH,Cl/kg. weight). Renal concentration was assessed by measuring urine osmolality after 14 hours of fluid deprivation. Three of 10 patients with SS, 2 of 12 with SLE, but none with RA, were found to have a n impairment of urinary acidification in that their urine p H failed to de- crease below 5.5 (>mean $3SD) after NH,C1 loading in spite of increased blood hydrogen ion concentrations. Also, a subnormal response was observed in the excretion of titratable acid and ammonium per unit of glomerular filtration rate in patients with SS and SLE but not in the RA group. No correlation was detected between the acidification abnormality observed and the duration of disease, drug history, gamma globulin concentration or renal biopsy findings. It is concluded that patients with SS and SLE without overt evidence of acid base imbalance may have a functional defect in renal acidification (latent renal tubular acidosis) of obscure cause. PHARMACOKINETIC STUDIES OF ACETYLSALICYLIC ACD RHEUMATOIDARTHRITIS IN PATIENTS WITH Stephen D. Sholkofl, Malcolm Rowland, Edward J. Eyring and Sidney Riegelman, San Francisco, Calif. Observations in this and other laboratories have suggested an alteration in acetylsalicylic acid ( ASA) metabolism in patients with rheumatoid arthritis. This report describes pharmacokinetic studies of ASA performed to determine whether a difference exists because of an abnormal absorption, chronic ingestion of the drug, or concomitant corticosteroid administration. We are currently investigating the effects of these factors on salicylic acid. The study groups consisted of rheumatoid patients on long-term ASA and corticosteroid therapy (Group I ) , rheumatoid patients on chronic ASA ingestion alone (Group I1 ), and normal volunteers ( Group I11 ) . A gas-liquid chromatography technique was used to measure the concentrations of ASA. The biological half-life of ASA in whole blood in vitro averaged 28 minutes for Group I, 26 minutes for Group 11, and 32 minutes for Group 111. ASA in solution was given to the subjects to study the kinetics in vivo. For Group I the peak plasma concentration averaged approximately 8 pg/ml and was reached between 15 and 21 minutes after administration. The half-life was 17.5 minutes. In Group I1 the peak plasma level was also approximately 8 #g/rnl and was reached between 15 and 21 minutes after administration. The half-life was 16.5 minutes. The peak ASA level in normal was approximately 10 /g,uml, attained in the range of 15 to 25 minutes after drug administration. The half-life for normal was 17.4 minutes. The results of these studies demonstrated no evidence for a significant alteration in the pharmacokinetics of ASA in rheumatoid patients caused by drug-induced tolerance, concomitant corticosteroid administration, or by abnormal drug absorption. THEEPIDEMIOLOGY OF DRUG-INDUCED SYSTEMIC LUPUSERYTHEMATOSUS ( SLE ) : COMPARATIVE DATA ON IDIOPATHIC SLE M . Siegel, S. L. Lee, and N . S . Peress, Brooklyn, N. Y. The epidemiology of drug-induced systemic lupus erythematosus has been investigated in New York City for the years 1957 to 1966. The study is based on a critical review of cases following prolonged use of four commonly implicated drugs, diphenylhydantoin, isoniazid, hydralazine and procainamide. The results on host factors and time trends obtained in 54 cases are compared with data on 101 cases of idiopathic SLE. An increase in the incidence of drug-induced lupus was observed, which was not apparent for idiopathic SLE. The increase was due to a sharp rise in cases attributed to procainamide in 1965 and 1966. This apparently is related to more widespread use of the drug as evident in the twofold increase in its sales. Comparative data on host characteristics are available for sex, age and race. 1) The prepon- 313 ABSTRACTS derance of females so typical of SLE was also years for drug-induced lupus and 35.8 years for observed for drug-induced lupus, although the SLE. 3) Unlike idiopathic SLE, there was no difference is less marked, particularly for isoniazid evidence of an increase in cases of drug-induced and procainamide. 2 ) The age groups affected Iupus among Negroes. varied with the population treated from an averThus, comparative epidemiological data on age of 33.4 years for epileptic subjects on drug-induced SLE and idiopathic SLE were rediphenylhydantoin to 60.7 years for patients with vealing of similarities and differences which may coronary occlusion and arrythmia treated with be of etiological significance. procainamide. The over-all mean age was 47.4 THEEFFECTOF AGGREGATION ON THE REMOVAL OF GAMMAGLOBULINFROM RHEUMATOID JOINTS Anthony 1. Sliwinski and Nnthan J . Zvaifler, Washington, D. C. Recent studies suggest that autologous gamma globulin and rheumatoid factor combine in the joint cavity causing the articular inflammation of rheumatoid arthritis. It has been proposed that rheumatoid factor retains aggregated gamma globulin in the joint, thereby localizing the injury. Heat aggregated gamma globulin treated with 2-mercaptoethanol reacts with rheumatoid factor but is not complement fixing or phlogistic. Autologous gamma globulin from sera of 6 patients with seropositive rheumatoid arthritis and one with osteoarthritis was mercaptoethanol treated. As much as 7.9 mgm. of autologous mercaptoethanol gamma globulin and 1.0 mgm of heat aggregated mercaptoethanol gamma globulin were introduced without producing joint inflammation. Autologous gamma globulin, mercaptoethanol gamma globulin, and heat aggregated mercaptoethanol gamma globulin were labeled with 1131 or 1125. The simultaneous disappearance of any two labeled proteins was followed by external counting over the knee. Autologous gamma globulin and autologous mercaptoethanol gamma globulin disappeared at similar rates (1.1 to 1.5 day half-life). Aggregation of autologous mercaptoethanol gamma globulin did not retard its disappearance from the knee 1.4 to 1.3 day half-life); the greater the aggregation the faster its disappearance. Similar results were obtained in osteoarthritis. Blood levels of heat aggregated mercaptoethanol gamma globulin were 2- to 200fold less than non-aggregated mercaptoethanol gamma globulin. The greater the alteration of the protein, the greater the difference noted. Radioactivity was non-dialyzable in the blood, but was dialyzable in the urine. These studies show that: 1) No joint inflammation was produced with autologous mercaptoethanol gamma globulin. 2 ) Aggregation of mercaptoethanol gamma globulin enhances rather than retards its removal from the joint. 3) No difference was noted between rheumatoid arthritis and osteoarthritis joints. 4) These findings do not support the proposed theories of joint inflammation. ON PULMONARY FUNCTION IN PATIENTS WITHPROGRESSIVE EFFECTOF D-PENICILLAMINE SYSTEMICSCLEROSIS J . Donald Smiley, Robert L. Johnson, Evaluation of drug effectiveness in progressive systemic sclerosis (PSS) is difficult because of the lack of objective criteria for improvement during JT. and Morris Zif, Dallas, Tex. short-term therapy. However, pulmonary function, particularly gas diffusion measurements, which may be repeated in the same patient with highly ~ Mean Values As % of Normal Pre-treatment Post-treatment Forced Vital Capacity Forced Expiratory Volume (1 sec.) Total Lung Diffusing Capacity (DL) Membrane Diffusing Capacity (U,) Total Lung Capacity 72.2% 70.2 59.3 51.4 82.5 71.2% 72.7 57.2 44.8 not done 314 ABSTRACTS reproducible results, offer an opportunity for controlled quantitative evaluation of response to therapeutic agents in PSS. Such pulmonary function was moderately to severly impaired in 11 patients treated with D-penicillamine ( Cuprimine), a drug which has been found to increase the soluble collagen content of the skin. Detailed tests were carried out before and after 4 to 5 months of treatment with one to 2 grams daily of this agent. Seven patients tolerated the drug for the complete treatment period. Results in these patients are shown. No objective clinical changes in other organ systems were noted following treatment. Two patients, not included above, who were treated with penicillamine without pulmonary function tests also showed no evidence of clinical improvement during the treatment period. Four patients showed gastrointestinal or allergic reactions requiring cessation of treatment after a few days. However, these were also re-evaluated and will be presented for comparison with the treated group. It is concluded that, in addition to producing severe toxic reactions in some patients, penicillamine failed to induce significant improvement in pulmonary function of patients with PSS during the time period studied in the dosage range utilized. CAPILLAROSCOPY AND BIOPSYSTUDY OF CUTANEOUS MICROANGIOPATHY IN SYSTEMIC LUPUSERYTHEMATOSUS N . M . Smukler, W. Redisch, E . J . Messinu, G. Hughes and J . P . Kulka, Boston, Mass. and New York, N. Y. Widespread distortion of the microvasculature in normal-appearing skin of patients with systemic lupus erythematosus has previously been demonstrated by in vivo capillaroscopy or alkaline phosphatase staining of tissue sections. The present investigation was designed to correlate the in vivo observations of this microangiopathy with the findings in quick-frozen biopsy specimens which permitted both three-dimensional visualization of the microvasculature and subsequent histologic study of paraffin sections. In 10 patients with systemic lupus erythematosus, rotary punch biopsies were obtained without use of anesthesia from nailfold, forearm or malleolar skin at sites which in all but one instance showed capillaroscopic evidence of microangiopathy. Abnormalities of the capillary loops included, in order of incidence, dilatation, a meandering course and pericapillary densities. Comparable changes were noted in 4 of the frozen-cleared preparations, even though these specimens failed to show evidence of inflammation or other histologic changes. I n 2 of the remaining 6 biopsies there was minimal focal inflammation and in 2 others slight focal erythrocyte extravasation. Although 6 patients were under steroid therapy at the time of biopsy, the occurrence of microangiopathy without associated inflammation was not dependent on steroid treatment, since it was also found in 2 patients who had received no such therapy. The finding of a distorted microvascular pattern, even without associated inflammation, in the skin of patients with systemic lupus erythematosus indicates that the microangiopathy is a basic manifestation of the disease. It is suggested that this underlying abnormality may predispose to the development of the clinical lesions. CLINICALSIGNIFICANCE OF THE “RA CELL” D. A. Sones, F. C . hlcDufie and G . G. Hu,ncler, Rochester, Minn. The diagnostic value of the presence of “RA cells” in synovinl fluid remains controversial. In an effort to evaluatc the significance of such leukocytic inclusions as an aid to early diagnosis of rheumatoid arthritis, fluids from 47 patients were studied. Twenty-nine patients had classic, definite or probable rheumatoid arthritis, 5 were classified as possible rheumatoid, G had nonrheumatoid inflammatory conditions and 7 represented non-inflammatory arthritis. Eighty-five per cent (25/29) of rheumatoid fluids demonstrated intraleukocytic inclusions but the lysed cell extracts of only 5 fluids contained demonstrable rheumatoid factor by the SingerPlotz latex and Ripley anti-Rh methods, and in each of these rheumatoid factor ( K F ) was also present in the synovial fluid and serum, urnally in high titer. Inclusions were aIso present in the leukocytes of 8 of the remaining 11 fluids (73 per cent) from patients regarded as having “inflammatory” arthritis ( 5 “poaaible” rheumatoids and G non-rheumatoid) but in none was rlieuma- 315 ABSTRACTS toid factor detected in the cell extracts. Only one of 7 “non-inflammatory” fluids revealed the presence of inclusions. Eight patients with monarticular arthritis suspected of having RA (one definite, 5 probable, 2 possible) were examined critically in the hope that the presence of RA cells might be of significant diagnostic help at an early stage. Though fluids from all 8 contained significant numbers of POLYMYALGIA RHEUMATICA WITHOUT THE these cells, the disrupted leukocytes of only one contained demonstrable rheumatoid factor, and in this patient RF was also present in serum and synovial fluid as well. Morphologically identifiable “RA cells” are a helpful index of inflammatory synovitis but are not of any specific diagnostic significance. Perhaps to avoid the implication of specificity the term “RA cell” should be avoided. CONSEQUENCES OF TEMPORAL ARTERITIS Harry Spiera, Charles M . Plotz and Sehan Dauison, New York, N. Y. Polymyalgia rheumatica is a clinical syndrome of unknown etiology and pathogenesis. It has been reported that biopsy of the temporal artery in some patients with this syndrome shows pathologic changes consistent with temporal arteritis even in the absence of clinical evidence of temporal arteritis. This has led to the suggestion that polymyalgia rheumatica is a variant of temporal arteritis. The authors have studied a series of 28 patients with the typical features of polymyalgia rheumatica for periods ranging from 6 months to 4 years. All patients were treated either with high doses of salicylates, or prednisone with a maximum dose of 10 milligrams a day. In no case did signs of a generalized arteritis appear nor was there any occurrence of visual impairment or blindness. One patient has died of an atherosclerotic mesenteric thrombosis. Sixteen patients have recovered completely and are in remission without medication. The rest are still under treatment. It would appear therefore on the basis of this experience that polymyalgia rheumatica is a benign syndrome with excellent prognosis in which symptoms can be effectively suppressed with salicylates or small doses of corticosteroids. Temporal arteritis, on the other hand, may be a serious disease, with blindness occurring in a substantial percentage of patients unless treated with large doses of corticosteroids. The benign natural history of polymyalgia rheumatica is such that when there is no clinical evidence of temporal arteritis, patients should be spared the potential hazards of high-dose steroid therapy. Further study is necessary to define the significance of vascular histopathologic changes in the elderly and to determine whether the mere presence of histopathologic changes in the temporal artery is sufficient to diagnose the clinical syndrome of temporal arteritis with its ominous prognostic implications. DEGRADATION OF PROTEINPOLYSACCHARIDE ( PP-L ) BY PUIUFIEDLYSOSOMES Isaias Spilberg and Gerald Weissmann, New York, N. Y. Although indirect evidence points to lysosomes as sources for enzymes which degrade cartilage matrix in arthritis, no direct proof has yet been obtained with purified subcellular fractions. Using discontinuous sucrose density gradients ( 1.8-1.4 M ), fractions of lysosomes rich in aryl sulfatase, beta-glucuronidase and acid phosphatase, but free of mitochondria1 enzymes, have been isolated from rabbit liver. Breakdown of bovine nasal cartilage PP-L was determined by measuring diffusion of uronic acid across millipore filters separating lucite chambers filled either with PP-L and bcffer, or buffer alone. Purified lysosomes (300 pg/piotein/ml) caused uronic acid to diffuse across filters ( 0 . 2 2 p ) from solutions of PP-L, to 10 per cent of the total uronic acid. After 2 to 3 hours’ incubation, negligible amounts of uronic acid (representing degradation of PP-L) diffused from PP-L alone, or from PP-L treated with boiled lysosomal extracts. Release of uronic acid from non-diffusable PP-L was time-and-temperaturedependent, and proportional to lysosoma1 enzyme concentration. In 0.1M acetate buffer, pH optimum for liver lysosomes was 4.6 to 5.0. Whole leucocytes disrupted by freezing and thawing also contained PP-L degrading activity, but such fractions were less active than pure lysosomal fractions, and released similar amounts of uronic acid at p H 4.6 and 7.4. Their activity was also abolished by boiling. Since these results could be duplicated by treatment of PP-L with trypsin, the effects of several protease inhibitors was tested and will be presented. These experiments demonstrate that highly 316 ABSTRA(;TS purified lysosomal fractions can degrade purified PP-L, and that this attack is proteolytic. Therefore, measures designed to stabilize lysosomes or to inhibit their enzymes might prevent breakdown of cartilage matrix in joint disease. THE“REACTED”LYMPHOCYTE-A CINERECORDING A. B. Stanfield, C . A. L. Stephens, IT., J . L. Parsons and J . B. Cubberly, Tucson, Ariz. Lymphocytes occurring in primary explants of synovialis in Rose chambers are observed to react characteristically but without agglutination when challenged with phytohemagglutinin. In addition to an increased mitotic rate, marked enlargement of many cells is observed. Large smooth nuclei with prominent nucleoli and a forerunner of clear cytoplasm are observed in the “reacted” lymphocytes. Pronounced pseudopods, frequently ending in fine cytoplasmic streamers, trail 2 to 3 times the length of the main body of the cells. A peculiar rolling motion of the nucleus occurs within the cells. Cinerecordings of cultures of rheumatoid lymphocytes challenged with sonicated synovial fluid also display an increase in mitotic rate and an enlargement of cells. For comparative purposes reacted peripheral lymphocytes transferred onto fibroblasts in chambers are included in the cinerecording. This experiment further emphasized the usefulness of this method for the long-term study and recording of both primary explant and peripheral lymphocytes and their response to a variety of immunologic, physiologic, and metabolic stimuli. A STRAINOF SYNOVIAL CELLSMITOGENIC FOR LYMPHOCYTES OF PATIENTS WITH RHEUMATOID ARTHRITIS Peter Stastny and Morris Ziff, Dallas, Tex. In the course of experiments in which rheumatoid synovium was cultured with buffy coat lymphocytes, a strain of cells was encountered which appeared to exert a selective mitogenic effect on lymphocytes from rheumatoid patients. Cell line D F was isolated from a 9-year-old juvenile rheumatoid patient undergoing synovectomy, and carried by weekly trypsinization and twice-weekly renewal of medium. Cultures containing 10 million buffy coat cells from rheumatoid patients and controls were set up in Eagle’s medium with 15 per cent fetal calf serum. Monolayer cells of D F were washed twice and added to the buffy coat cultures at concentrations of 20 X 103 and 100 X lo3 cells per flask. After 6 days, tritiated thymidine (HaTdr) was added and the cells allowed to incorporate label for 6 hours. Incorporation of H3Tdr into DNA was determined by liquid-gel scintillation counting. The HSTdr incorporation of D F cells alone was negligible, but when they were added to buffy coat cells from 10 rheumatoid patients, a 2.1 to 7.3-fold increase in HsTdr incorporation resulted, mean increase 4.6t 1.8. The mean of 13 nonrheumatoid controls of miscellaneous type was 1.8 2 0.6 (p<O.Ol). Twelve other rheumatoid and 6 non-rheumatoid synovial cell lines as well as several lines of fibroblasts from skin have not shown a difference in response on the part of rheumatoid patients and controls. Cell line D F did not exert a significant mitogenic effect on allogeneic buffy coat cells of control individuals, whereas 6 other rheumatoid cell lines tested did so. This would suggest that the selective ability of D F cells to stimulate lymphocytes from rheumatoid patients may represent an unmasking of an effect not ordinarily detectable in allogeneic cell mixtures. It appears possible that strain D F may be deficient in one or more of the usual complement of surface antigens of the transplantation type. The nature of the apparent rheumatoid specific reaction observed is at present not known. EFFECTSOF INTRA-ARTICULAR ANTI-METABOLITES Marvin E. Steinberg, Richard W. Cohen and Frederick C . Cogen, Philadelphia, Pa. Although the intra-articular injection of antimetabolites in the treatment of rheumatoid arthritis has recently received considerable atten- tion, almost no basic animal investigation has been reported. Thus, little evidence of gross or histological change within the injected joints has been 317 ABSTFiACTS presented and neither potential effectiveness nor safety has been directly established. One hundred thirty-three young and adult rabbits received injections of either Nitrogen Mustard, Thio-tepa or Methotrexate into the left knee and sterile saline into the right. Doses were varied and were given either singly or at 3 weekly intervals. Animals were sacrificed at intervals ranging from one day to 12 weeks. Clinical effects, gross appearance of joints and histological changes were noted. After Nitrogen Mustard injection changes were moderate to marked in virtually all joints. Gross and histologic destruction of articular cartilage, epiphyseal plates and adjacent bone was noted. There was no evidence of synovial obliteration, although inflammatory changes and fibrosis in sub-synovial layers occurred. After Thio-tepa or Methotrexate injection no severe reactions occurred, even with high doses. Articular cartilage, epiphyseal line and adjacent bone were unaffected. Synovium generally was unaltered or showed only minimal reaction, although in a few cases mild fibrosis occurred. Thus Nitrogen Mustard showed no selective synovial obliteration, and caused such severe and generalized joint damage that its clinical use would be hazardous. Thio-tepa and Methotrexate, although showing little selective synovial effect in the normal knee, would appear relatively safe to other intra-articular structures. Their potential value in the treatment of rheumatoid arthritis is being investigated experimentally and clinically. RESPONSETO IMMUNIZATION IN SLE May Betty Stevens, Murray B . Urowitz, Lawrence M . Mulhern and Lawrence E . Shulman, Baltimore, Md. Efforts to demonstrate abnormal antibody responses to foreign antigens in patients with SLE have yielded conflicting results. In the present study, the response to Vi antigen was evaluated in 12 patients with SLE and 12 normal controls matched for age, sex, and race. By design, 6 patients with SLE had nephritis. Forty gamma of the antigen were administered subcutaneously and anti-Vi titers determined by a hemagglutination technique using .%fold serum dilutions. Serial serum specimens obtained during the immunization period were also examined for change in serologic activity. The kinetics of the antibody response was the same for all patients and all controls, with an induction time of 7 to 10 days. In 9 of 12 patients with SLE,the anti-Vi titer increased by 5 or more tube dilutions. Only 2 of the 12 controls showed a response of this magnitude. Furthermore, the increment in anti-Vi titer was greater in patients with lupus nephritis than in the lupus patients without nephritis. The degree of reactivity to Vi antigen did not correlate with any of the serologic abnormalities of SLE. Moreover, in no patient did immunization with Vi evoke an “anamnestic” response with respect to the autoantibodies of SLE or increase their titer. These data indicate that patients with SLE tend to respond more vigorously than do normals to immunization. It is further suggested that there may be significant immunologic differences between lupus patients with nephritis and those without renal disease. MOVEMENT ON THE DEVELOPMENT OF LESIONS IN EFFECTOF EXAGGERATED ADJLWANT DISEASEOF RATS Michael S. Stulbarg, L. Peter Einstein, Yves Van Schoote and J. Peter Kulka, Boston, Mass. Immobilization or denervation of a limb has been observed to influence the severity and localization of peripheral lesions in patients with rheumatoid arthritis. We investigated the role of tissue movement in a comparable systemic disorder by studying the effect of exaggerated tail bending on the development of local connective tissue lesions in rats with mycobacterial adjuvant disease. The middle half of the tail was braced, forcing the animal to bend excessively the segment proxi- mal to the brace. Braces, made of metal rods held together by Elastoplast bands, were applied to 25 animals before or after adjuvant injection, for periods of 4 or more days. Control animals with weighted Elastoplast bands were used to rule out the effect of possible constriction by the bands and of extra weight on the tail. The proximal portion of the tails of all braced animals developed a large fusiform lesion which was in contrast with scattered maculo-papules and subcutaneous nodules of the controls. This result 318 ABSTRACTS was obtained even when bracing extended only to the eighth day of the latent period, 2 or more days before the onset of arthritis. The tail lesions usually appeared earlier in braced animals than in controls, and were more commonly associated with limitation of motion. These findings indicate that the mechanical stress resulting from excessive motion of an extremity may localize and intensify connective tissue lesions in systemic inflammatory disease. The ability to produce such lesions consistently at a specified site will facilitate study of the pathogenetic mechanism and possible therapeutic measures. DEFICIENCY RHEUMATICMANIFESTATIONS ASSOCIATEDWITH IMMUNOGLOBUIN Stanley Tobias, Eugene V. Barnett and Carl M . Pearson, Los Angeles, Calif. A high incidence of “auto-immune” disorders and lymphoreticular neoplasms has been noted in hypo-y-globulinemia. Reported here are 2 cases of hypo-y-globulinemia and 2 cases of dys-yglobulinemia, each with one or more associated rheumatic manifestations or neoplasms. M.G. is a 49-year-old white female with recurrent infections since age 12. At age 43 she noted progressive weakness. Muscle biopsy revealed focal interstitial myositis and vasculitis. Muscle enzymes were normal. There was persistent mild leukopenia. yG was 200 mgm per cent; yA<20 mgm per cent; yM, 22 mgm per cent. S.L. is a 70-yearold white female, well until age 61 when she presented with diarrhea which totally remitted in 10 months. This was followed by recurrent otitis, sinusitis and bronchitis. At age 65 a benign thymoma was removed. At age 66, there was migratory polyarthralgia. An adenocarcinoma of the uterus was resected. yG was <lo0 mgm per cent; yA, <20 mgm per cent, yM, <10 mgm per cent. M.P. is a 25-year-old white female with a 21-year history of recurrent superficial vasculitis and skin ulcers. Biopsy revealed obliterative vasculitis. Cryoglobulins were present, but there were negative ANA, LE tests. yG was 600 mgm per cent; yA, 30 mgm per cent; yM, 142 mgm per cent (Type I dys-y-globulinemia). B.T. is a 51-year-old white female with no prior history of infections. At age 50 she had acute onset of febrile illness characterized by purpura, peripheral neuritis, nephritis, hypertension, myocarditis, splenomegaly, thrombocytopenia, hemolytic anemia and polyserositis. ANA, negative; latex, 1 :20,000; and complement depressed. yG was 200 mgm per cent; yA, 64 mgm per cent; yM, 420 mgm per cent (Type I dys-y-globulinemia). A high incidence of rheumatic disorders with immunoglobulin deficiency may imply an infectious etiology. A pathogenetic role for small amounts of auto-antibodies in these disorders is not excluded. COMPARISON OF SERUMURATECLEARANCE BY DALMATIAN DOG, A NON-DALMATIAN AND A DALMATIAN WITH A TRANSPLANTED NON-DALMATIAN LIVER Richard 3. Tompkins, Paul H . Andreini, John T . McCall and L. Emmerson W a r d , Rochester, Minn. The significantly higher urinary uric acid excretion in Dalmatian dogs compared to nonDalmatians has not been satisfactorily explained. Although it has been proposed that the difference is primarily due to defective renal tubular reabsorption of urate, non-Dalmatian kidneys transplanted into nephrectomized Dalmatians have been reported to excrete as much uric acid as do Dalmatian kidneys. Other data suggest that defective hepatic conversion of uric acid to allantoin in the Dalmatian may be important. Serum uric acid levels following intravenous uric acid loads remain elevated significantly longer in Dalmatians than in non-Dalmatians. Since the Dalmatians have been found to possess at least as much liver uricase activity as other breeds, it has been proposed that an intrahepatic defect sequesters the uric acid from the uricase. In the present study 30 mg. of uric acid per kgm. body weight was injected into the leg vein of a Dalmatian, a non-Dalmatian and a Dalmatian with a non-Dalmatian liver transplant ( 4 months post-transplantation with no evidence of hepatic dysfunction). Serum uric acid was measured in blood drawn from the jugular vein. The results showed nearly identical serum uric acid clearances in the non-Dalmatian and the Dalmatian with the liver transplant, both being significantly greater than in the intact Dalmatian. This, as well as the urinary uric acid excretion data from these dogs, indicates that the altered metabolism of urate in the Dalmatian can be almost entirely explained by an hepatic defect. 319 ABSTRACTS LONG-TERM FOLLOW-UP OF NORMAL INDIVIDUALS WITH POSITIVE TESTS FOR RHEUMATOID FACTOR Elam Toone and Marion Waller, Richmond, Va. Positive tests for rheumatoid factor have been associated with a variety of diseases other than rheumatoid arthritis, and an increased incidence of positive tests have been observed in elderly individuals without evidence of rheumatoid disease. Moreover, it has been recognized that rheumatoid arthritis need not coexist with, antedate, or even follow the demonstration of positive tests for rheumatoid factor. Nevertheless, the prognostic implication of high titers of rheumatoid factor in normal individuals allow for considerable conjecture; and consequently, the observation of these individuals over a period of several years has been attempted. In a survey for rheumatoid factor in 5461 presumably normal individuals, 12 individuals were found to have SHC titers in excess of 1:320. However, on physical examination, 3 had possible or probable rheumatoid arthritis. One individual was not examined, and the other 8 individuals were entirely normal. This report will deal with the follow-up study of 3 of these normal individuals who have been under observation from 6 to 9 years. Each demonstrated positive tests with high titers when they first came under study and have maintained positive tests for rheumatoid factor over the entire period. Each has undergone complete physical evaluation, x-ray study, and laboratory tests, and none shows evidence of rheumatoid arthritis. The implications of these studies, embracing certain minor laboratory and physical changes, will be discussed. SCLERODERMA AND HEREDO-FAMILIAL DISEASE: STUDIESOF THREE FAMILIES D. L . Tuflanelli, San Francisco, Calif. In the present study the families of 3 probands with scleroderma, all demonstrating unusual aggregations of immunological and genetic aberrations, are presented. In the first family the mother of the propositus was an XO/XX Turner mosaic. Two siblings had mental retardation, spastic diplegia and congenital ichthyosiform erythroderma. In the second family the proband’s mother had both rheumatic fever and rheumatoid arthritis, a sister had multiple sclerosis and her son was a Trisomy 21 mongol. In the third family the mother had lupus erythematosus and a sister had died of glomerulonephritis. The proband with scleroderma also had a monoclonal IgG gammopathy. Chromosomal and serological studies, including serum electrophoresis, fluorescent antinuclear antibodies, LE factor, antibody to gamma globulin, and quantitative immunoglobulin levels have been done on 21 first-degree relatives and have demonstrated a familial clustering of abnormalities. The incidence of chromosomal abnormalities, other connective tissue disorders, and immunological abnormalities in these unusual families supports the hypothesis that scleroderma may be genetically predetermined. THEINFLUENCE OF AGEON THE CLINICAL PATTERNOF SYSTEMIC LUPUSERYTHEMATOSUS Murray B. Urowitz, Mary Betty Stevens and Lawrence E. Shulman, Baltimore, Md. The influence of age on the clinical expression of systemic lupus erythematosus (SLE) has not been evaluated. It has been our impression that the pattern of SLE emerging in the older age groups differs from the clinical picture seen in the young. The present study was undertaken to test the validity of this impression. Of 106 cases indexed as “lupus erythematosus” at The Johns Hopkins Hospital during 1963-1965, 82 fulfilled predetermined criteria for the diag- nosis of SLE. All clinical and serologic manifestations of SLE in these patients were recorded, and analyzed according to decade of age. As seen in the table below, certain features of SLE, namely cutaneous lesions, articular involvement and lymphadenopathy, were more common in the young and decreased progressively with age. In contrast, the pneumonitis of SLE was more frequent in the older age groups. 320 ABSTRACTS Age at Dx (years) 10-19 20-29 30-39 4-49 50 and over Total NO. Pts. Skin 21 15 23 14 9 16(76%) 12(80%) 14(61%) 8(57%) 3(33%) There were no correlations between age and the prevalence of other features of SLE, including nephritis. Moreover, there was evidence that SLE in the elderly was a milder disorder than that in the young. The average duration of symptoms before diagnosis in those under 20 years of age was 14 months; it increased progressively to 50 months Manifestations of SLE Joint Lymph Nodes 21 (100%) 15 (100%) 22 (96%) 12 (86%) 5 (56%) 14(67%) 14(93%) 10(44%) 4(29%) 2(22%) Lungs 4(19%) 3(20%) 10(44%) 5(36%) 5(56%) in the oldest age group, suggesting a more subtle disease in the latter. In addition, the corticosteroid dosage requirement was lower in the older patients than in the younger ones. These data, therefore, indicate that age does exert a modifying influence on the clinical expression of systemic lupus erythematosus both in its individual manifestations and its severity. SENESCENT PIGMENTATION OF CARTILAGE Jan K . tlan deT KOTSt, Leon Sokoloff and Edward J. Miller, Bethesda, Md. The pathologic significance of progressive pigmentation in the aging of animal tissues is the subject of current interest. Lipofuscins are inert, but it has been suggested that they may, by occupying sufficient cytoplasmic space, embarrass the vital activities of cells. Another group of pigments, less well characterized chemically, affects connective tissues; there have been some recent speculations that they may be involved in cross-linking of fibrous proteins. Analogy of the pigmentation of old cartilage to ochronosis was drawn by Virchow in his original description of this entity. So far as we know, no systematic description of non-alkaptonuric pigmentation of cartilage in relation to the aging and degenerative disease of joints has been made. For this reason, the pigmentation of patellar and costal cartilages, quadriceps tendon and intervertebral discs was studied in 55 necropsies on patients 1 to 70 years of age. The pigment first appeared in rib cartilage in the last half of the third decade, and increased in degree thereafter. The color of the costal cartilage and tendon generally paralleled each other within each individual. The pigment was bleached slowly by 30 per cent hydrogen peroxide, but resisted extraction by 5 M guanidine, acid, alkali or fat solvents. By various histochemical procedures, ultraviolet microscopy and low temperature emission spectroscopy, it could be distinguished from lipfuscin, ceroid, melanin, hemosiderin or lipchromes. It likely represents one or more polymeric derivatives of aromatic amino acids. Although the surface of articular cartilage in old or osteoarthritic persons frequently appears slightly brown, this apparently is the result of staining by synovial fluid. The relative sparing of articular cartilage from senescent pigmentation is one more property in which this tissue differs biologically from other cartilages and connective tissues. No association was found between the severity of degenerative joint disease and the pigmentation of the various connective tissues. MANIFESTATIONS OF RHEUMATOID ARTHRITIS FOLLOWING STROKE Edward E. Velayos and B. Stanley Cohen, Baltimore, Md. Rheumatoid arthritis and hemiplegia are relatively common conditions, but their coexistence in the same patient has been described infrequently. In 6 cases previously reported, hemiplegia present at the onset of rheumatoid arthritis has been shown to exert a protective effect on the joints of the paretic side. The statement has been made that pre-existing rheumatoid arthritis is not amel- iorated by subsequent hemiplegia, and, in fact, a single case report in the literature suggests the converse. The present report is concerned with a patient with long standing rheumatoid arthritis who developed hemiplegia. Over the next several years, changes were noted in the subcutaneous nodules, in the degree of ulnar deviation, and in the 321 ABSTRACTS relative severity of radiographic findings on the 2 sides. In each instance the paretic side showed less involvement. In addition symptoms were largely confined to the uninvolved extremities. The previously reported cases are reviewed and the possible mechanisms and avenues for future investigation are discussed. OF ERYTHROCYTES SENSITIZED WITH THE RIPLEYANTI-RK AUTOLOGOUS AGGLUTINATORS WITH 14 DIFFERENT PROTEOLYTIC ENZYMES ANTIBODY DIGESTED Marion Waller, Richmond, Va. Erythrocytes sensitized with Ripley anti-Rh antibodies digested with 14 different proteolytic enzymes have revealed an astonishing array of autoagglutinators to his own enzymatically degraded anti-Rh antibodies. These autoagglutinators have comparable counterparts ( isologous agglutinators) in most human sera. They were found to be IgG globulins, were serologically distinguishable from the IgM rheumatoid factors and were unrelated to his anti-Rh antibodies. The enzymes could be arbitrarily divided into 3 groups in respect to the serologic manifestations of the enzymatic degradation. The characteristics of each group of enzymes will be discussed. The gamma globulins digested for various lengths of time revealed relationships between agglutinator titers, anti-Fc titers and bivalency and univalency of the anti-Rh antibodies. Heterologous anti-Fc antisera absorbed with Fab fragments prepared with a variety of proteolytic enzymes have revealed differences heretofore undetected. AORTICANEURYSM AND RHEUMATOID ARTHRITIS Howard J. Weinberger and Harry Sacks, Los Angeles, Calif. Rheumatoid heart disease with aortitis and aortic valvulitis is a generally accepted clinical entity. Aortic aneurysm in rheumatoid arthritis (RA) has been reported previously in one patient. Three females with RA and aortic aneurysm have been observed by us. The first patient, age 67, had the onset of stage IV, class IV, RA in 1946. Progressive aneurysmal dilatation of the sub-clavian, ascending and transverse aorta was noted in 1951, and aortic insufficiency in 1953. Hypertension, coronary artery and peripheral vascular disease also were present. Anti-luetic therapy for a benign false positive serology was given in 1941 and 1953. Autopsy in 1961 showed aortic histopathologic alterations consistent with syphilis, although a rheumatoid basis could not be excluded. Obliterative pericarditis was also present. The second patient, age 57 years, developed arthritis in 1962. Pericarditis, mediastinal mass, transient aortic insufficiency, and paroxysmal arrhythmias were noted in 1964. The patient was normotensive. Aortography was inconclusive. At thoracotomy, aneurysm of the ascending aorta with intra-luminal clot and totally adherent pericardium were found. Biopsy of the aorta showed a chronic mononuclear cell inflammatory reaction. Blood and spinal fluid serologic tests for syphilis (STS) were negative. Aortic insufficiency and cardiomegaly have been progressive. The third woman, age 67, had low-grade polyarthritis for 15 years with acute exacerbation in the knees one year ago. History and STS were negative for lues. Blood pressure was 120/80. Aortic aneurysm was found 6 months ago. Biopsy of the knee and synovial fluid examination were consistent with RA. Sudden death occurred 2 months ago, presumably related to aneurysmal rupture. The clinical and histopathological findings, though inconclusive, suggest an association between RA and aortic aneurysm rather than ail unusual coincidence. RHEUMATOID NODULESIMULATING BASALCELL CARCINOMA K . R. Wilske and L. A. Healey, Seattle, Wash. Rheumatoid nodules are known to occur at sites of pressure, and thus they usually appear about the elbows and over the occiput and sacrum. We have seen 6 patients, each with a rheumatoid nodule in an unusual location, the bridge of the nose. All had classic rheumatoid arthritis. Five had high titers of rheumatoid factor and many nodules in the customary locations. In addition, three had a nodule on the ear. All 6 patients wore glasses, and it is postulated 322 ABSTRACTS that the pressure from the nose piece of the eye glass frame led to the formation of the nodule in this area. These nodules tended to drain and form eschars. Both their location and their appearance with a central ulcer surrounded by a raised rolled border suggested basal cell carcinoma. I n 2 patients, the lesion was excised and showed the characteristic histology of a rheumatoid nodule. In the others, it gradually cleared spontaneously. URIC ACID LITHIASISIN PRIMARYGOUT: ANALYSISOF 280 CASES Ts’ui-fan Yii and Alexander B. Gutmun, New York, N.Y. Of our 1258 cases of primary gout, 280 (22 per cent) gave a history of uric acid lithiasis. Two factors were found to predispose to stone formation: 1 ) increased uric acid concentration in the urine; 2 ) low urine pH. With increasing urinary uric acid excretion the incidence of calculi rises, reaching 50 per cent of the cases when the output exceeds 1 gm/day. The urine in primary gout tends to be unduly acid, pH<5.0 in about a third of the cases (early morning specimens), 5.1 to 5.3 in another third. There is also minimal diurnal fluctuation in urine pH; the alkaline tide is diminished or absent in many cases. This persistent undue acidity of the urine is attributable to deficient urinary ammonium excretion. In 111 cases of primary gout (with or without stone), free of detectable renal impairment, the mean urinary NH,+ excretion was 25 to 30 per cent lower than that in the nongouty; in the pH range 4.8 to 5.6, 24.2 2 6.4 pEq/min in the gouty, 33.0 2 7.3 pEq/min in the nongouty ( p < O . O O l ) . No difference in titratable acid was detected in early morning urine specimens. Seventy cases of uric acid lithiasis in gout who did not respond to conventional alkali and hydration therapy were treated with allopurinol. The results were sufficiently satisfactory to indicate that allopurinol is the drug of choice in the management of uric acid lithiasis in gout. THE ROLE OF ANAEROBIC BACTERIAIN BONE AND JOINT INFECTIOKS Irwin Ziment, Luwrence G. Miller, Alvin Duuis and Sydney M . Finegold, Los Angeles, Calif. A review of the literature reveals a paucity of reports on anaerobic infections of bones and joints. No report has been found of any systematic investigation into the prevalence of anaerobes in these conditions, and their incidence and pathogenic role still remain undetermined. Since 1959 we have found 14 cases of osteomyelitis at Wadsworth Veterans Administration Hospital in which anaerobes have been cultured from pus and/or resected bone; in addition, we report one case of anaerobic arthritis. Anaerobic cultures were not made routinely in these types of cases but only in selected instances. The cases fall into four categories: 1 ) Osteomyelitis of the foot, mainly in diabetics-6 cases; 2 ) Osteomyelitis associated with mastoid or sinus disease-5 cases; 3 ) Osteomyelitis of long b o n e 4 cases (one diabetic, also in Category 1);4 ) Acute pyogenic arthritis-1 case. Isolates included B. frugilk-11 strains; B. melaninogenicus-7; B. funduliformis4; Fusobacterium-2; Bifidobucterium-1 ; and anaerobic cocci -9. In only 2 instances were anaerobes (Bacteroides) present in pure culture; in the mixed infections aerobes were present also. Clues to the possible presence of anaerobes in these patients were 1 ) failure to isolate a potential pathogen on routine culture of frank pus-6 patients, 2 ) foul odor to purulent discharge-10 patients, 3 ) presence of gas in t i s s u e s 3 patients, 4 ) necrosis in soft tissues-3 patients, 5 ) presence of pleomorphic organisms resembling Bucteroides on direct gram stain of p u s 4 cases, and 6 ) black discharge due to presence of B. melaninogenicus-1 patient. D-PENICILLAMINE THERAPY IN RHEUMATOID ARTHRITIS lack Zicckner, Robert H . Ramsey, Robert W. Dorner and George E . Ganfncr, Jr., St. Louis, Mo. The u5e of penicillamine offers a new approach to the treatment of patients with rheumatoid arthritis. Its effect on macroglobulins, copper, sulf- hydryl levels, pyridoxine metabolirm and collagen poses interesting speculation about basic mechani5ms of action in its relationship to results 323 ABSTRACTS obtained in rheumatoid arthritis. Fifteen rheumatoid patients received d-penicillamine for a period of approximately one year. The daily dosage was 1 to 2 grams, usually given in 4 divided doses. Improvement graded as good or excellent was obtained in 7 patients; 2 others derived benefit which questionably fell into this group. Improvement was first noted after 1-1/2 to 2-1/2 months of therapy in G patients; after 3 to 4 months of therapy in 2 ; and after 6 months in one case. Toxicity appeared in 9 patients, including bad taste in 4, canker sores in 2, agranulocytosis in 1, skin odor in 1, and epigastric distress and nausea in 1 each. Rheumatoid factor titre diminished in all of 14 patients who had elevated values at the onset of therapy. The sedimentation rate decreased in 9 patients. By immunodiffusion techniques using Hyland plates, it was shown that gamma M levels decreased in 8 cases; gamma G levels diminished in G patients, but also increased in 1; and gamma A levels were not significantly changed. Serum ceruloplasmin levels (Hyland plates) were lowered in 5 patients, and possibly in 2 others. Cultures for lymphocyte transformation were performed 228 times at varying periods during the study; penicillamine caused no significant inhibition of this reaction. Correlation of these laboratory results with the clinical status was not demonstrated. CORRELATIONS IN LUPUSNEPHRITIS SERIALCLINICAL-PATHOLOGIC Burton Zuieiman, Joan Kornblum, John Cornog and Eugene A. Hildreth, Philadelphia, Pa. Increasing attention is being directed to renal involvement in the morbidity and mortality of systemic lupus erythematosus. Some observers cIassify lupus nephritis into several pathologic patterns differing in prognosis and therapeutic consideration. They have noted little progression from the milder to the more severe histologic picture over a follow-up period. They also found certain urinary findings highly suggestive of severe histologic patterns. In the situation where renal biopsy was not feasible or available to the clinician, such urinary findings might imply prolonged use of high-dosage steroid therapy. A study comparing the clinical and histologic findings at initial renal biopsy has been made in 39 lupus patients. These correlations have then been evaluated in light of subsequent clinical and histologic courses ( mean duration of follow-up4 yearr ), including antinuclear factor determinations. A frequent lack of correlation between renal clinical and histologic findings was found. Ten patients exhibited one or more urinary abnormalities in the absence of significant histopathology or evidence of infection. These patients generally showed no clinical progression of renal disease. Two of them showed some histologic worsening. Five subjects showed histologic abnormalities in the absence of any clinical evidence of renal disease. None of these patients have shown gross clinical evidence of renal disease and the serial histologic patterns have been stable. Twenty patients initially had both significant clinical and histologic renal abnormalities. Three of them with the severe initial histologic pictures died in renal failure. Clinical and/or histologic progression of renal disease has occurred in four of the survivors. Conclusions at this time are: 1 ) There is a frequent lack of correIation between clinical and pathologic findings. Urinary abnormalities without pathologic change have not been commonly associated with progression of renal disease. Therefore, in the absence of biopsy data, one cannot accurately predict the nature of the pathoIogic process with therapeutic and prognostic implications. 2 ) Although patients with both clinical and histologic renal abnormalities have fared worst, 14 of 19 such patients are alive (mean duration3 years ) after initial study. Relationships between clinical course and treatment in these patients will be discussed. MEDIUMCHAIN TRIGLYCERIDES IN THE TREATMENT OF INTESTINAL PROGRESSIVE SYSTEMIC SCLEROSIS E . S. Rfongan, M . S. Kleinman, and I. M . Samloff, Rochester, N . 1’. A female patient, age 58, with proven small-intestinal involvement caused by progressive systemic sclerosis (PSS ) developed severe malabsorption associated with abdominal distension, borborygmi after meals, a 6-kilogram weight loss, anemia and frequent periods of diarrhea. Two periods of tetra- cyline therapy of one month duration produced no therapeutic effect. The patient was studied on a metabolic ward where dietary fat intake and fecal fat excretion were measured. On a low fat diet supplemented by 65 grams of medium chain triglycerides (MCT) 324 per day, the daily fecal fat excretion fell from 38.2 g/d to 16.0 g/day in 2 weeks and the patient’s symptoms improved markedly. She maintained the clinical improvement on MCT dietary supplements at home for the next month. The patient was re-studied by placing her on a normal diet. Her symptoms promptly recurred. Quantitative cultures from the jejunum revealed 4 x 10 8 colonies of E. coli per milliliter sensitive to kanamycin. A 12-day course of 4 grams of kanamycin per day produced a significant change in the bacterial flora of the jejunum and in fecal fat excretion, but did not affect her symptoms. Peroral intestinal biopsies of the jejunum before, ABSTRAmS during and after MCT and kanamycin therapy showed no significant- change. All the biopsies showed patchy villous atrophy similar in appearance to the changes found much more extensively in non-tropical sprue. A gluten-free diet resulted in reversal of the villous changes toward normal but did not alter fat excretion or the patient’s symptoms. These results suggest that a marked curtailment of the amount of long-chain fatty acids usually found in American diets and the substitution of MCT may have a beneficial effect in patients with severe malabsorption due to intestinal PSS.