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40

10

80

50

2 0

90

60

30

6/25 7/16 7/30 9/24 10/22 12/10

=GRIP STRENGTH (average) A =20 Ib. DOLORIMETER W = A M STIFFNESS (hours) 0 = 10 Ib. DOLORIMETER a =ONSET FATIGUE (hours) = LANSBURY ARTICULAR INDEX

Fig. 2.-The clinical course of a 62-year-old man with seropositive rheumatoid arthritis illustrates the greater sensitivity of the 20-pound dolorimeter in certain instances. The grip strength, morning stiffness, onset of fatigue and Articular Index were each determined as described by Lansbury.2

Cyclophosphamide vs. Conservative Treatment of Rheumatoid Arthritis

Sir: I believe that it would be in order to compare

the data of Fosdick, Parsons and Hill on cyclo- phosphamide therapy in rheumatoid arthritis (Ar- thritis Rheum. 11:151, 1968) with the results of another study.

This trial reports that 75 per cent of patients are “markedly improved” on long-term therapy. Data on functional class and erythrocyte sedimen- tation rate (ESR) are presented in detail.

The composition of this series is similar in some respects to the carefully studied population of conservatively treated rheumatoids followed by Duthie and his associates (Ann. Rheum Dis. 23: 193, 1964). Since no control group is included, perhaps this series could be used as a contrast @oup.

The initial data are quite similar, as are the end results. Fosdick had 15 per cent fewer patients in class 111, but Duthie had 15 per cent more

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Fosdick Duthia

Functional c h s evaluation: Steinbrocker Steinbrocker Malek/fem&s: 5/33 88/219 Age-years: 23-63, median 43 mean 44 Duration of disease-years: 2-31, mean 14.3 mean 6.5 Follow up-months: 6 4 0 , median 23 1250, mean 24.4

(first assessment) Severitv Six months of “progres- “Severe enough to be twcessary for sive active arthritis with selected for hospital inclusion: deterioration” treatment”

The second table shows Fosdick’s functional class data before and after therapy, and Duthie’s data on admission and at the first assessment.

in each function class

Fosdick ( cyclophosphamide) Duthie (Aspirin, bed rest, P.T.)

I I1 111 IV I I1 I11 IV Before: 0 34.2 44.8 21.0 0 35.4 42.6 22.0 After: 13.2 73.7 10.5 2.6 28.4 44.0 25.1 2.5

patients who improved into class I. If groups I and I1 are combined, Fosdick‘s results are better, but if mean functional class is used, the results are the same. Fosdick‘s data on ESR are impressive. Duthie has noted the patients with high initial ESR’s tend to do well.

Another possible conclusion is that the improve- ment Fosdick noted is probably no better than that which might have been seen with bed rest, aspirin and physiotherapy. A survey of results of other conservatively treated groups (Short and Bauer, New Eng. J. Med. 238:142, 1948) reveals results which are about as good.

The authors describe this therapy as “promis- ing.” and at the same time state “side effects . , .

were minimized with the protocol folIowed in this study” and that “CP is relatively safe. No cases of fatal bone marrow depression have been reported.” Other workers using small doses of other chemo- therapeutic agents in arthritis have had more difficulties with side effects. Mortalities of 5 per cent (Black, O’Brien, et al., J.A.M.A. 189:743, 1964) and 8 per cent (Lorenzen and Videbaek, Lancet 2:558, 1965) have been reported. The use of very large doses of both cytotoxics and corti- costeroids after renal transplantation had resulted in mortalities of as great as 48 per cent (R. B. Hill et al., New Eng. J. Med. 271:1021, 19G4).

WILLIAM O’BRIEN, M.D. Charlottesoille, Virginia

Twin Veterans

Sir: 1 would like to call the attention of your readers

to a possibly misleading statement in an interesting article entitled “Twin Studies in Rheumatic Dis- rase,” by William O’Brien which appeared in the February 1968 issue of your Journal (Arthritis Rheum. 1161, 1968). Dr. OBrien refers to a twin registry compiled and maintained by the Follow- up Agency, Division of Medical Sciences, National Rcsearch Council, stating that, “The Veterans’ Ad- ministration has collected a list of 54,000 male

twin pairs of whom at least one member of the pair served in the Armed Forces during World War 11.”

The Follow-up Agency receives funds and serv- ice support from the Veterans Administration for the conduct of medical follow-up and epidemio- logic studies. Some of these funds and services have been used by the Twin Registry; however, its primary financial support at this time comes from the Institute of General Medical Sciences, National Institutes of Health. The conduct of spe-