To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left-and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in 2 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81

The efficacy of cyclobenzaprine (Flexeril), as compared with placebo, was tested in a 12‐week, double‐blind, controlled trial of 120 patients with fibrositis. Of the patients who received placebo, 52% dropped out due to lack of efficacy of the drug, compared with 16% of patients taking cyclobenzaprine. The dropout rate due to adverse reactions was similar in the 2 groups. Patients taking cyclobenzaprine experienced a significant decrease in the severity of pain and a significant increase in the quality of sleep. There was a trend toward improvement in the symptoms of fatigue, but morning stiffness was not alleviated. These improvements in symptoms were associated with a significant reduction in the total number of tender points and in muscle tightness. Our findings indicate that cyclobenzaprine is a useful adjunct in treating patients with the fibrositis syndrome.

An extracellular fluid phase (Cf 1), aspirated by micropuncture techniques from the hypertrophic cell zone of calcifying epiphyseal cartilage, has been characterized in a calcifying system in vitro in respect to the behavior of sedimenting and supernatant fractions after high speed ultracentrifugation. To perform these tests on the starting samples of 20 nI of Cf 1, macroscopic analytical methods were scaled down for the identification of relevant organic components, including hexuronic acid and proteinpolysaccharides (PPL). The mineral accretion system was designed to simulate physiologic conditions in the calcifying cartilage septa of normal rats, and the mineral used for seeding was an immature calcium phosphate similar to native cartilage mineral. Normal Cf1 or its dilutions in synthetic lymph up to 1: 4 completely prevented mineral accretion in vitro. The inhibitory action was localized to the sedimented fractions after ultracentrifugation and could be destroyed by incubation with trypsin or hyaluronidase. The sediment of Cf1 contained 2 mg of hexuronic acid per ml of Cfi and gave a strong reaction of identification for a light fraction of PPL by fluorescent antibodies to rat PPL. PPL fractions were tested in the same mineral accretion systems as Cfi and exhibited responses similar to those of Cf1. Also, there was evidence of a mineral phase in Cf of normal rats, in Cf of rats with healing rickets, but not in Cf of untreated rachitic rats. These results are interpreted to indicate that certain PPLs function as an inhibitor of crystal growth at extracellular sites premonitory to calcification. Evidence for a low density inhibitor of mineral accretion was found in normal serum but not in Cfl.

SYNDROME OF RECURRENT painful periarticular lesions associated with roentgenographically demonstrable calcification was recently described by Pinals and Short.' These authors suggested ( a ) that a fundamental defect in connective tissue exists in these individuals, and ( b ) that the inflammation observed was mediated by the preformed ectopic mineral phase. The purpose of this paper is to report three additional patients with a similar clinical course and to describe limited pathologic and crystallographic findings in typical lesions.Patient #l. C. O., a 67-year-old white woman of Italian descent was admitted to Hahnemann Hospital on 9/21/64 because of pain in the left knee. Although an ill-defined, intermittent, transient aching had been present for 5 weeks, severe pain was first noted on 9/19/64 during attempted weight bearing after arising from bed in the morning. Tenderness, warmth and cutaneous erythema were localized to the lateral aspect of the left knee. Mild tenderness was also elicited in the right wrist and in the ankle and subtalar joints bilaterally. The oral temperature was 99.4 F.Previous attacks of acute inflammation had occurred intermittently over a period ot approximately 30 years; 3 attacks of "bursitis" were described, once in the right and twice in the left shoulder. The proximal tarsal area was unilaterally involved on one occasion. The lateral aspect of each knee previously had been acutely symptomatic. Except for intermittent mild morning stiffness in the wrists, no musculoskeletal symptoms were noted between attacks. Moderate diastolic hypertension had been present for 5 years and thyroid had been prescribed for hypothyroidism diagnosed clinically by her family physician 3 years before. Soft tissue calcifications were visualized roentgenographically in the capsule of the left shoulder and in the lateral collateral ligaments of both knees ( Fig. la-b). Laboratory findings are listed in Table 1.A provisional diagnosis of gouty arthritis was made by the admitting resident. Colchicine therapy, 0.5 mg. every hour for 10 hours, resulted in moderate relief of pain and subsidence of warmth and erythema. Marked tenderness over the lateral collateral ligament of the knee persisted; 0.5 ml. of clear, viscous fluid was removed by needle aspiration of the left knee joint. Microscopically, no crystals were visualized in a wet smear by phase-polarized light.z Aspiration of a small fluctuant mass at the site of maximum tenderness yielded 0.5 ml. of thick, white liquid; 40 mg. of triamcinolone diacetate were injected through the same needle. Microscopic examination of a "wet smear" revealed innumerable globular bodies varying from 3 to 65 p in diameter (Fig. 2a). These "shiny coin" bodies

SIMPLE INSTRUMENT ( "dolorimeter" ) for precise quantification of A articular tenderness is described herein. The systemic and articular indices of Lansbury' have been used routinely for over 4 years in our clinics to estimate rheumatoid activity; the instrument to be described was developed as an extension of this experience. The Lansbury "articular index" is the sum of numerical "scores" assigned to inflamed joints based on an estimation of relative surface areas. In this system inflammatory "activity" is determined by elicitation of localized tenderness by firm digital pressure over, or by pain on, passive motion of a joint, In our experience, the articular index has been uscf ul in determining the initial degree of involvement and subsequent "spread" of disease activity. The number and relative size of the inflamed joints are taken into consideration but the relative intensity of the inflammation in each one is not, except by roughly scoring a joint as '?/z" or " 2 X its normal point value.Thc recent description of the "palpameter" by Hollander2 also stimulated the dcvelopment of the present instrument. The "palpameter," a device resembling sugar tongs, provides a five pound scale for quantification of tenderness. In our experience, however, the small scale has proved difficult to read accurately; moreover, the tips of the instrument impart a torque force as well as direct pressure on the joint. DESCRIPTION OF INSTRUMENTDorland's medical dictionary provides 2 names for this type of instrument-"dolorimeter" and "algesiometer." In formal discourse, we prefer the former name." The present instrument is similar in principle to a device described as the "palpometer" by Steinbrocker in 1949.3 It is adapted from a commercially available push-pull gauge ( fig. 1) .fThe instrument is approximately 19 inches long, weighs 13 oz., and provides a 4 inch scaIe reading from 0 to 10 pounds avoirdupois. The stainless steel spring is calibrated to f 1 graduation ( 2 oz.); the tension on the spring may be adjusted by turning a small knob provided for this purpose. The casing is of chrome plated braqs. A maximum reading pointer allows for greater accuracy and eliminates error due to parallax when the instrument is not used