RHEUMATOLOGY (Greek rheuma, rheumatos a flow, the expiration, rheumatic suffering + logos the doctrine) — the section of medicine studying an etiology, a pathogeny, clinical manifestations, treatment and prevention of rheumatic diseases.
About 85 nosological forms which are characterized by defeat of connecting fabric, a musculoskeletal system and vessels including inflammatory rheumatic diseases (a pseudorheumatism and other chronic diseases of joints, acute rheumatism, diffusion diseases of connecting fabric, microcrystallic arthritises) belong to rheumatic diseases; degenerative diseases of joints and backbone (arthroses and spondylarthroses); diseases of muscular and tendinous and periartikulyarny fabrics (tendovaginitis, periarthritis, bursitis, miozita, etc.), exchange osteopathy.
In the International statistical classification of diseases, injuries and causes of death (1975, the IX review) rheumatic diseases are carried preferential to diseases of a musculoskeletal system and connecting fabric (the XIII class). In the USSR in 1971 at the I All-Union congress of rheumatologists the «Working classification of diseases of joints and extraarticular soft tissues of a musculoskeletal system» including actually rheumatic diseases united in group I «Main forms of diseases of joints and a backbone», and also arthritises and arthroses connected with other diseases, making the II group was accepted. Fullestly the list of rheumatic diseases is presented to classifications of the American rheumatological association accepted in 1963 and dividing all rheumatic diseases into 13 groups (it is brought with small reductions): I. Polyarthritises of an unknown etiology (pseudorheumatism; juvenile pseudorheumatism; ankylosing spondylitis; psoriasis arthritis; syndrome of Reuters). II. The «connective tissue» frustration acquired (a system lupus erythematosus; the progressing system sclerosis; polymiositis and dermatomyositis; necrotic arteritis and other forms of vasculites; amyloidosis). III. Rheumatism. IV. Degenerative diseases of joints. V. In not joint rheumatism (fibrosites; the syndromes connected with defeat of intervertebral disks; miozita and mialgiya; tendinites and peritendinites, bursitis; tenosinovita, fascites, syndrome of a carpal tunnel). VI. Diseases, to-rye often are followed by arthritis (a sarcoidosis; recurrent polychondritis; Shenleyn's purpura — Genokh; ulcer colitis; regional enteritis; Whipple's disease; Shegren's syndrome; family Mediterranean fever). VII. The arthritises caused by the famous infectious agents. VIII. Traumatic and (or) neurologic disturbances (traumatic arthritises; neuropathic arthropathies or Sharko's joints; a syndrome «a shoulder — a brush»; mechanical disturbances of joints). IX. The diseases connected with known or reasonable the suspected biochemical or endocrine anomalies (gout; joint chondrocalcinosis; alkaptonuria; hemophilia, acromegalia, etc.). X. Tumors of joints. XI. Allergic and medicinal reactions. XII. Hereditary and inborn diseases (Marfan's syndrome; haemo cystinuria; Elers's syndrome — Danlosa, etc.). XIII. Various other disturbances (pigmental villonodulyarny sinovyt; Bekhchet's syndrome; knotty erythema; recurrent panniculitis; aseptic necroses of bones; juvenile osteochondritis; the cutting osteochondritis; multiformny erythema; hypertrophic osteopathy; multicentric retikulogisti-otsitoz; the disseminated lipogranulomatosis, a family lipochrome-ny pigmental arthritis; syndrome to Tittsa; trombotichesky Werlhof's disease, etc.).
This classification, as well as others, is not deprived of shortcomings and contentious clauses, but differs in the greatest completeness.
In the general structure of diseases rheumatic diseases possess a considerable share. According to WHO data (1979), from 12 to 25% of all patients using system of primary health care have rheumatic diseases, and about 5% of all koyko-days fall to the share of patients with these diseases. According to statistical data of various countries, incidence of rheumatic diseases makes from V20 to x / 5 the general incidence of the population.
Great social value of rheumatic diseases is defined by a preferential porazhaye-most of persons young and average, i.e. the most efficient, age, a tendency to the chronic or recuring them current and considerable level of temporary and resistant disability among such patients.
To the second half of the 19th century rheumatic diseases were known very little and any joint pains and muscles were estimated as rheumatic. Only two considerable discoveries were made a little earlier: G. I. Sokolsky and Zh. Buyo established connection of damage of heart with rheumatic polyarthritis, and Garrod (A. V. of Garrod) proved communication of gout with a hyperuricemia. In the second half of the 19th century many really rheumatic diseases were described: dermatomyositis (see), a nodular periarteritis (see. Periarteritis nodular ), system lupus erythematosus (see), pseudorheumatism (see), Bekhterev's disease (see. Bekhtereva disease ). But also after that, for a long time, for designation of many diseases which are characterized by defeat of a musculoskeletal system the term «rheumatism» (joint, chronic, muscular) called by N. A. Velyaminov «depository point where dump all those forms of diseases of joints was unfairly widely used, we cannot classify to-rye we behind almost complete ignorance of essence of these diseases».
The subsequent period of history P. (till 20th years 20 century) is characterized by development and deepening of representations about rheumatism (see) as system disease with peculiar kliniko-anatomic manifestations. To this R. it is obliged to S. P. Botkin, A. A. Kisel, M. A. Skvortsov, V. T. Talalayev, L. Ashoff's works. On formation of modern ideas of an etiology of rheumatism G. M. Malkov's works, etc. had a great influence, in to-rykh dependence of a disease on a streptococcal infection is for the first time established. The important stage in R.'s development relating to the same period is connected with F. Muller's proposal to differentiate diseases of joints on two basic groups: inflammatory — arthritises (see) and dystrophic — arthroses (see) that formed the basis for development of scientific classification of diseases of a musculoskeletal system.
Since the middle of the 20th years significant progress in the area P is noted. Big prevalence of rheumatic diseases, first of all rheumatism (to 17% according to population researches), puts them in one row with tuberculosis and epidemic infections. Fight against rheumatism begins to be considered as a social problem. N. A. Semashko considered an obligation of the state to struggle with very grave illnesses of the population that extends as well to fight against rheumatism. Such approach to this question formed the basis for formation of the International antirheumatic league (1928), creation of the national antirheumatic organizations in many countries, carrying out the International congresses of rheumatologists (the fourth of them was carried out in Moscow in 1934). In our country in 1928 the All-Union committee on studying of rheumatism and fight against it was formed (chairman M. P. Konchalovsky), then sections of committee in various cities are founded; rheumatological clinics and offices were created, in activity to-rykh from the very beginning importance it was given to prevention and in communication in these to studying of communication of rheumatic diseases with working conditions and life. In 1938 the publication of committee — the Acta rheumatologica magazine began to be published. In 1934 on the basis of Clinical children's hospital in Moscow (the former Morozovskaya) at the initiative of A. A. Kisel the rheumatological clinic — the country's first specialized institution of this kind was open. In the same years begins to develop intensively studying of joint pathology, the foundation to Krom laid N. A. Velyaminov, M. M. Diterikhs, B. P. Kushelev-sky's works in the USSR.
In 20 — the 30th years the list of rheumatic diseases was replenished with Felti's syndromes (see. Felti syndrome ), Horton (see. Arteritis giant-cell ), Shegrena (see. Shegrena syndrome ), Wegener (see. Wegener granulomatosis ), Bekhcheta (see. Bekhcheta disease ).
By 60th years R. was finally allocated in the independent section of internal medicine that was promoted by Klempererom formulated in 1942, Pollack and Rem (P. Klemperer, A. D. Pollack, G. Baehr) idea of «diffusion diseases of connecting fabric» (see. Collagenic diseases ), to the Crimea they carried «the acute and chronic diseases which are characterized by anatomic damages of connecting fabric, especially its extracellular components». This, for the time the new and progressive approach which indicated common features in pathology of a number of rheumatic diseases promoted significant progress of River. Considerable and fruitful impact on its development was exerted also by progress immunology (see) and emergence of the doctrine about autoimmune diseases and about immunopathologies (see) in general. Opening of such autoimmune phenomena as LE cells by Hargreyvs (M. of Hargraves, 1948), a rhematoid factor Voler were of great importance for improvement of diagnosis of rheumatic diseases (E. Waaler, 1939) and antinuclear factor Hezrik (J. Haserick, 1949). At this time considerable development was gained by the doctrine about inflammation (see), having a direct bearing on a pathogeny of many rheumatic diseases, the concept about microcirculation was formulated, the role is established lysosomes (see) and systems complement (see), many mediators of an inflammation are open.
Considerably strengthened R.'s independence clearly come to light to 60 — to the 70th years success of implementation of penicillin in treatment and prevention of rheumatism. Positive takes were achieved also in treatment of other rheumatic diseases thanks to use of corticosteroids, and then and cytotoxic drugs.
In 1947 the European antirheumatic league is created, under aegis cover 1 time in four years the European congresses of rheumatologists began to be carried out (the tenth congress took place in Moscow in 1983). In 50 — the 70th years in many countries are created research rheumatological institutes: institutes of rheumatic diseases in Prague and Pyeshtyanyakh (ChSSR), institutes of rheumatology in Warsaw and Belgrade, Institute of rheumatology and balneology in Budapest, Institute of rheumatism of Kennedy in London, Institute of arthritises, metabolism and diseases of the digestive system as a part of National institute of health in the USA and so forth. In 1958 in Moscow the Institute of rheumatism was open (nowadays Institute of rheumatology).
The big contribution to R.'s development was made by schools of the USA, France, England, Finland, Italy, Poland, Czechoslovakia and a number of other countries. From domestic rheumatological schools it should be noted A. I. Nesterov's schools, E. M. Ta-reeva and A. I. Strukova. Achievements of these scientists in the field of rheumatology were noted by the Lenin award in 1974.
In the world more than 30 magazines devoted to questions of rheumatology are issued. In the USSR since 1961 the Revmatologiya magazine is issued (since 1983 — «Questions of rheumatology»).
Modern R. studies an etiology, a pathogeny, clinic, diagnosis, treatment and prevention of rheumatic diseases. Undoubted success is achieved in the field of theoretical R., the etiologies of inflammatory rheumatic diseases consisting in development of virus and genetic and bacterial and genetic concepts. The role of urogenital and intestinal infection in an etiology of a disease of Reuters is established (see. Reuters disease ), postinfectious arthritises and sacroileites; indirect demonstrations of a role of a viral infection in development of a pseudorheumatism and system lupus erythematosus are obtained. Value of genetic predisposition to development of a number of rheumatic diseases is shown. The available data indicate the high frequency of inflammatory diseases of joints, especially Bekhterev's diseases, at HLA B27 carriers of antigen. In R. the problem of an autoimmunity and an immunopathology as at the basic rheumatic diseases (rheumatism, a system lupus erythematosus, a pseudorheumatism, other diseases of connecting fabric) development of pathological process is the cornerstone immunopathological mechanisms figures prominently. Also studying of mechanisms of disturbances of metabolism of connecting fabric, the reasons of its disorganization, in particular in a cartilage belongs to fundamental problems P. at degenerative diseases of joints, and also studying of a pathogeny of an inflammation.
One of the most important directions of practical R. is development of early and differential diagnosis of rheumatic diseases. It is promoted by widespread introduction in clinic immunological, immunomorfo logical, biochemical and other laboratory methods of a research; use of the tool diagnostic methods (radiological, radiological, ultrasonic, endoscopic, etc.) allowing to estimate more deeply and precisely a condition and function of various bodies and systems; development of the unified (criteria) approach to diagnosis. Improvement of methods of polydirectional, combined medical effects and methods is so important rehabilitations (see). In addition to pharmacological means, in treatment of rheumatic it is painful great importance are also orthopedic (operational and conservative) of methods of treatment, physical therapy (see), balneology (see), methods physiotherapy exercises (see) and massage (see).
Organization of the rheumatological help. The rheumatological service in the USSR for adult population is created in 1979. It succeeded the cardioroar-matologichesky service existing 20 years.
For these two decades the wide experience of fight mainly against rheumatism at adults and children was accumulated. The harmonious system of the specialized help to the population which is carried out by rheumatological offices of policlinics and well osnashchennsh the rheumatological centers in republican, regional, regional and large municipal hospitals cooperating with the relevant departments of hospitals developed and gained the most wide spread occurance. To-rykh exceeds rheumatological offices of policlinics, number 3000 (for adults and children), conduct work on identification of patients, formation of the dispensary contingent, dispensary observation. The rheumatological center performs direct management of offices, provides the large volume of the advisory help, solves problems of diagnosis and the choice of methods of treatment for the most difficult patients. The organization of the rheumatological help to children is carried out by cardiorheumatological offices of children's policlinics.
One of the most important aspects of activity of the rheumatologist is dispensary observation of patients. Till 1979 under dispensary observation there were only patients with rheumatism. Efficient component medical examinations (see) the bitsillino-aspirinovy prevention of a recurrence of rheumatism (with free allocation of Bicillinum) which found the most wide spread occurance in our country was. Decrease in number of a recurrence more than by 3 times, essential reduction of cases and days of temporary disability, decrease in indicators of an invalidism and increase in life expectancy of patients with rheumatism was result of a sistvkhma of dispensary observation of patients with rheumatism. In 1979 on the basis of the accumulated experience of the organization of fight against rheumatism the problem of coverage was put forward by dispensary observation of patients with other major rheumatic diseases. Patients with a coxarthrosis and gonartrozy were put under dispensary observation also sick with a pseudorheumatism, Bekhterev's disease, diffusion diseases of connecting fabric, and also.
Dominance among the specified diseases of the diseases of a musculoskeletal system which are characterized by a tendency to progressing and an invalidism with a special force sets a task of development and deployment in practice at early stages of development of diseases of system of rehabilitation. One of the most important tasks of rheumatological service (for adults) and cardiorheumatologists especially-chesky service (for children) is further development of system of purposeful preventive actions among the population with coverage them, first of all, the contingents connected with risk factors in relation to rheumatism and diseases of joints.
See also Arthrology .
History — Velyamino in N. A. The doctrine about diseases of joints, L., 1924; D and t e r and x with M. M. Introduction to clinic of diseases of joints, M. — L., 1937; Konchalovsky M. P. Clinical lectures, century 1, M. — L., 1935; Kushelevsky B. P. Clinic of rheumatic and not rheumatic infectious arthritises, Sverdlovsk, 1938; N of the EU of t e r about in A. I. Ocherk of studying of rheumatism and diseases of joints, M., 1951; T are of e e in E. M. Evolution of the doctrine about collagenoses in clinical aspect, M., 1975.
Textbooks, guides, reference media — Astapenko M. G. and Eryalis P. S. Extraarticular diseases of soft tissues of a musculoskeletal system, M., 1975; Vorobyov I. V. and Lyubomudrov V. E. Nodular periarteritis, M., 1973; A mustache e in and N. G. System scleroderma, M., 1975; L I am m p e r I. M. Etiologiya's t, immunology and an immunopathology of rheumatism, M., 1972; Nasonova V. _a. System lupus erythematosus, M., 1972; Nesterov A. I. Rheumatism, M., 1973; Nesterov A. I. and Nasonova of V. A. Sostoyaniye and perspectives of the Soviet rheumatology, Vopr. revm., No. 2, page 3, 1978; Nesterov A. I. and Sigidin Ya. A. Klinika of collagenic diseases, M., 1961; Effects of rheumatic diseases and fight against them, Chronicle of WHO, t. 33, J4 ° 5, page 241, 1979; Rheumatology, under the editorship of V. T. Tsonchev, the lane with bolg., Sofia, 1965; Guide to the international statistical classification of diseases, injuries and causes of death, page 245, Geneva, WHO, 1980; The reference book on rheumatology, under the editorship of V. A. Nasonova, M., 1978; Studenikin M. Ya., etc. Children's arthrology, L., 1981; Yaryg of N of H. E., Nasonova V. A. and Funs and on R. N. System allergic vasculites, M., 1980; Arthritis and allied conditions, ed. by J, L. Hollander a. D. J. McCarty, Philadelphia, 1972; Primer on the rheumatic diseases, Chicago, 1983; Textbook of the rheumatic diseases, ed. by W. S. Copeman, Edinburgh — Livingstone, 1969; Textbook of rheumatology, ed. by W. N. Kelly a. o., Philadelphia a. o., 1981.
Periodicals — Questions of rheumatism, M., since 1961; Annals of Rheumatic Diseases, L., since 1939; Arthritis and Rheumatism, N. Y., since 1958; Bulletin on Rheumatic Diseases, N. Y., since 1956; Journal of Bone and Joint Surgery, Boston, since 1919 (1903 — 1918 — American Journal of orthopedic surgery); Revue du rhumatisme et des maladies ost6o-artieulaires, P., since 1934; Rheumatology and Rehabilitation, L., e 1973; Rhumatologie, P., since 1971; Scandinavian Journal of Rheumatology, Stockholm, since 1972; Zeitschrift fur Rheumafor-schung, Dresden — Lpz., since 1939; Zeitschrift fur Rheumatologie, Dresden — Lpz., since 1974.
A. I. Speransky; A. Yu. Bolotina, E. H, Maksakova (organization of the rheumatological help).