One hundred patients with "definite" or "classical" rheumatoid arthritis were followed in a hospital clinic from within one year of the onset of the arthritis. The average interval between onset and first attendance was 3.7 months. Onset was commoner in the winter, transient prodromal symptoms being noted in 23, with possible precipitating factors in 14. The serum rheumatoid factor test was positive at some time in 88.The patients were reassessed between eight and 14 years later. Seventeen died during this period, five possibly as a result of the disease or its treatment.The remaining patients had improved as a whole in terms of the blood sedimentation rate, haemoglobin, titre of the rheumatoid factor test, and status of the disease, but there was an overall deterioration in functional capacity. Both the rheumatoid factor titre and the functional capacity at an earlier review could be directly correlated with the outcome, but other factors were not found to influence the ultimate prognosis.

The histological appearance of percutaneous superficial paraspinal muscle biopsy specimens from eight patients with ankylosing spondylitis was compared with that of biopsy specimens from 13 control patients with similar degrees of disability and spinal immobility due to severe, chronic mechanical back pain. In both groups marked type I muscle fibre atrophy was shown. Additionally, in patients with ankylosing spondylitis there were obvious increases in perifibre connective tissue in association with central migration of cell nuclei but without evidence of inflammation. Qualitative electromyography failed to show denervation changes in either group. Paraspinal muscle fibrosis, occurring over and above atrophic changes due to disuse, seems to be a specific pathological component of ankylosing spondylitis which may be of particular importance in early disease as it may contribute towards back stiffness and weakness.

Two patients with pachydermoperiostosis were studied in whom the predominant features at presentation were severe and disabling knee and ankle joint pain in association with distal long bone pain. Analysis of synovial fluid from the knee joints showed non-inflammatory changes. In one patient a bicortical iliac crest bone biopsy specimen, taken after labelling with A radiological examination showed a periosteal reaction along the distal ulnae, tibiae, and fibulae and a bone scan using labelling with strontium 87 confirmed increased isotope uptake at these sites. A synovial biopsy sample from the right knee showed venous dilatation without inflammation whereas a biopsy sample of skin from the ankle showed gross dermal thickening with hypertrophy of the sweat glands. A biopsy sample ofthe tibial metaphysis, after labelling with demeclocycline, showed normal osteoid seams with minimal separation of the labelled lines, indicating that the hyperostosis was relatively inactive.Pachydermoperiostosis was diagnosed, the increased hydroxyproline excretion reflecting the increased metabolic rates of collagen and bone. In view of the severity of the patient's joint pain, which had responded poorly to treatment with NSAIDs, a trial with high doses of corticosteroids was thought to be justified (enteric coated prednisolone, 50 mg/day) and the effects were monitored biochemically using the excretion levels of urinary hydroxyproline. These decreased towards normal values rapidly but the symptoms continued intermittently and improved only gradually. By 1979 the patient still had disabling joint pain and his 24 hour urinary hydroxyproline excretion was still raised, at 32 mg/M2, but he was now working full time and the prednisolone, which had been gradually reduced, was discontinued. The patient subsequently continued to have joint symptoms, which were not progressive, and he remains otherwise well.PATIENT 2In 1989 a 17 year old healthy white boy developed severe pain and swelling of his knees and ankles after playing football. There was no