The author's methods of systemic and articular indexes have been an important advance in the field of evaluating disease activity and response to therapy in patients with rheumatoid arthritis. The present paper summarizes his experience with these methods and his present views on this controversial subject.Per su methodologia del indices systemic e articular, le autor ha promovite importantemente le evalutation del activitate marbide e del responsa therapeutic in patientes con arthritis rheumatoide. Le presente articulo summarisa su experientias in le us0 de su methodos e su vistas currente con respecto a iste thema controverse.

In the field of rheumatism, one of the most pressing needs is for a standardized, objective, and reliable index of the activity of rheumatoid arthritis which, while not taking into account all the manifold manifestations of the disease, will nevertheless provide a trustworthy guide both to its course in individual cases and to therapeutic responses in multi-clinic trials. In this paper we present a summary of our previous work on the development of a Systemic Index which, we believe, fulfills this function. We also give an outline of the Articular * Presented at the IX International Congress on Rheumatic Diseases at Toronto in June, 1957. Index by which various joint findings may be summed up numerically.

My purpose in submitting the following six case reports is to call attention to what is, I believe, a significant and little recognized relationship between neoplastic disease and the so-called "collagen" group of rheumatic or connective tissue diseases. The first case, observed in 1946, was so striking that a careful watch was kept for similar cases. The vigil was rewarded over a period of 7 years by another five cases. The case reports have been reduced to a bare minimum-summaries of pertinent positive information-since the object in view is to illustrate the coexistence of two obvious diseases in each patient rather than to prove the correctness of the diagnosis by furnishing a multiplicity of detailed evidence. Case 1. Male, aged 44, a blind musician, was first seen in the Temple University Arthritis Clinic in June, 1946. History.-He had had painful joints of 4 months' duration. The arthritis had a rather sudden onset and spread rapidly, so that in a few weeks the shoulders, elbows, wrists, metacarpophalangeal and proximal interphalangeal joints, and knees were involved. Examination.-Physical examination disclosed the typical findings of rheumatoid arthritis with fusiform swelling, tenderness, limitation of motion, muscle atrophy, and weakness. Other findings included a harsh systolic murmur heard over the whole praecordium, congenital amblyopia, poor nutrition, a chronic cough, and seborrhoeic dermatitis. The erythrocyte sedimentation rate (Cutler) was rapid, the electrocardiogram (by Dr. Hugo Roesler) indicated a primary myocarditis and possible pericarditis with no features suggesting rheumatic fever. 15 mm./l hr (Cutler). Therapy.-She was treated with a programme of extra rest, salicylates, testosterone, and local shrinkage of the nasal mucous membranes. In the following 3 months the articular symptoms improved, but the muscle stiffness persisted. She died elsewhere in August, 1947. Autopsy (performed locally).-Widespread peritoneal metastases were revealed. Comment.-This case illustrates the appearance of a low grade rheumatoid arthritis occurring during the course of a fatal malignancy. It is possible that the 301 by copyright.

Serial appraisals of rheumatoid activity by the systemic and articular indexes, performed by seasoned observers on patients who were accustomed to this type of examination, show an interobserver variation no greater than interlaboratory variations in determinations made on stock samples for uric acid, albumin and hemoglobin. However, the variation found when medical students examined new patients was considerably higher. Interobserver variation was not significantly greater than intraobserver variation. The precision and sensitivity of the various items composing the indexes are compared.Evalutationes serial del activitate rheumatoide a base del indices generalisate e articular, executate per experte observatores in patientes accostumate a iste type de examine, monstra un variation inter le observatores non plus grande que le variation inter laboratorios in le caso de determinationes a base de specimens standard pro acido uric, albumina, e hemoglobina. Tamen, le variation trovate quando studentes de medicina examinava nove patientes esseva considerabilemente plus alte. Le variation inter observatores non esseva significativemente plus grande que le variation intra le corpore de observationes del mesme observator. Es comparate le precision e le sensibilitate del varie componentes in le indices. METHOD FOR EVALUATING the inflammatory activity of rheuma-

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