Observations on Rheumatology in the U.S.S.R. By CTJRRIER MCEWEN The author, who was a member of a scientific exchange team which visited the U.S.S.R. in September and October 1962, reports his observations made during visits to rheumatologic research institutes and laboratories in Moscow, Leningrad and Kiev. Le autor esseva membro de un gruppo scientific de excambio visitante le U.R.S.S. in septembre e octobre 1962. Ille reporta le observationes que ille faceva in le curso de visitas in institutos de recerca rheumatologic e lor laboratorios in Moscova, Leningrad, e Kiev. D URING the period September 26 to October 13, 1960, the author had the privilege of being a member of a scientific exchange team which visited the U.S.S.R. under the auspices of the United States Department of State and Public Health Service. The observations which follow are based on the experiences of that trip. When this manuscript was completed it was held because of uncertainty as to the accuracy of some of the details. However, on his trip to the United States in December 1962, Academician A.l. Nesterov kindly read the manuscript and made revisions and corrections. It is, therefore, submitted with confidence as to its accuracy and with thanks to Professor Nesterov for his assistance. Organization Research, teaching and patient care in the field of Rheumatic Diseases throughout the U.S.S.R. are coordinated and controlled by an' All-Union Committee responsible jointly to the Ministry of Health and the Academy of Medical Sciences. Academician A.I. Nesterov serves as Chairman of this committee and Professor Margarita Astapenko, of the former's staff, as Secretary. The functionk of the Committee include the establishment of a nomenclature and classification of rheumatic diseases, the setting of standards for diagnosis and treatment, and the review and coordination of all research on arthritis and rheumatism throughout the U.S.S.R. The committee controls research also in the sense of deciding what work is to be done. Main activity in' research on rheumatic diseases is centered in the Institute of Rheumatism in Moscow, but there are smaller research units in other cities of which we visited several in Leningrad and Kiev. These will be described briefly below. Care of Patients Since our mission was concerned with research and time was limited, we did not visit any of the general hospitals or out-patient clinics. However, From the Department of Medicine and the Rheumatic Diseaszs S t u d y Group, N e w York Univmsity Medical Center, NEW York, N . Y. These obseroations were made possible by Grant A-3636 from U S P H S . 623 ARTHRITIS AND RHEUMATISM,VOL.7, No, 6 ( QZGSEMBER), 1964 624 CURRIER MC EWEN the various rheumatism centers which we visited had clinical services of 35 to 130 beds for the care and study of patients with rheumatic fever, rheumatic heart disease, rheumatoid arthritis, systemic lupus and other collagen’ diseases. I saw several men with ankylosing spondylitis and one woman with psoriatic arthropathy but no examples of degenerative joint disease or gout. Indeed, the latter two are not sought since they are outside the area of active interest of these research units and are considered the province of investigators in the fields of geriatrics and metabolic disorders. Subsequent care of patients is done mainly in big gerieral out-patient clinics not connected directly with the research units, but the patients are called back to the latter for care and follow-up observations. Methods of treatment will be considered in the discussion of the individual centers. Nomenclature and Concepts The All-Union Committee on Rheumatism has adapted a classification of rheumatic diseases which is official for the U.S.S.R. This was kindly sent to me by Academician Nesterov and is appended to this report. As will be seen in the classification, rheumatoid arthritis is called non-specific infectious arthritis. The term rheumatism commonly means rheumatic fever. NOTESON INDIVIDUAL RHEUMATIC DISEASE CENTERS Moscow STATE INSTITUTE OF RHEUMATISM: This large institute, which is directed by Academician A. I. Nesterov and is under the jurisdiction of the Academy of Medical Sciences, is the only one of its kind in the U.S.S.R. It was established in 1958 in an old but well-kept building which Napoleon’ used as his home and headquarters during the French occupation of Moscow in 1812. The first two floors house the research laboratories and the Director’s office; the third floor is devoted to the clinic (meaning in-patient service) of 90 beds; and there is a small fourth floor which contains a laboratory for routine clinical tests. Laboratory space is very adequate. Equipment is ample. Much of it is of Soviet make, but apparatus of German, Swedish, English and United States manufacture also is present. The work of the Institute is carried out in three main divisions: clinical, experimental and methodological, each of which will be described below. I was told that there are 73 scientific staff members and about 87 technicians. The overall plan of research in all divisions is set by a Scientific Council which is under the guidance of Academician Nesterov as Chairman. Teaching per se is an incidental function of the Institute staff, but, of course, all junior staff members are obtaining advanced education. In addition, clinical trainees, called “ordinati,” spend two years in the Institute, and research fellows (“aspiranti”) spend three years and then move on to other research units or become regular junior staff members of the Institute. At the time of my visit to the Institute, there were five ordinati and four aspiranti. RHEUMATOLOGY IN THE U.S.S.R. 625 Academician Nesterov speaks little English but is quite proficient in German. Dr. A. A. Rogov speaks fluent English, and many others understand and read it quite well and can make themselves understood fairly adequately. Clinical Department This is the largest. It consists of three subdivisions concerned respectively with rheumatic fever, rheumatoid arthritis and the “rare collagen diseases”, plus x-ray, physical therapy and rehabilitation, clinical chemistry, sanatorium units for children, and a laboratory of functional diagnosis. Rheumatic Fever Subsliu.lsiorx Academician Nesterov himself heads this unit which has 50 beds in the Institute. A unit of 50 beds for children with rheumatic fever and rheumatic heart diseases is situated some miles away in the “green zone” of Moscow. This clinic, which is under the immediate direction of Dr. Alexandra Degopolova, I was not able to visit. Adult patients are cared for in the Institute proper. The entire third floor has been remodeled into very adequate wards of two to 12 patients each. The staff for taking care of all the patients on the floor was sufficient to provide about one physician to every five patients. Treatment appeared to be similar to that in the United States. Cortisone, prednisolone and triamsinolone were the corticosteroids principally employed. Academician Nestemv believes that the combined use of salicylates and steroids gives better results thad either alone. Cortisone (or equivalent doses of other steroids) is started at 300 mg. daily which is quickly dropped to 200 and then 100 mg. daily, and is then more slowly reduced. A total course is 3 to 4 gm. of cortisone or a therapeutically comparable amount of prednisolone. At the onset of treatment penicillin is given for a 10 day period and seasonal prophylaxis of rheumatic fever by bicillin and aspirin for six weeks is advised thereafter at the time of peak incidence of the disease. The concept of the disease currently held is that the triggering mechanism is hemoIytic streptococcal infections, chiefly in the form of tonsillitis and pharyngitis. The Soviet rheumatologists agree that infection is only part of the mechanism of the disease and that the nature of the other part, namely individualIy changed immunologic reactivity, is yet unknown. They are currently working on the principle that allergy plays a great role in the pathogenesis of the disease, perhaps on an autoimmune basis. In addition, Academician Nesterov believes that “higher nervous activity” plays an important role, and electroencephalographic study is included in’ the investigation of each patient. Rheumatoid Arthritis: This clinical subdivision, which has about 25 beds, is under the direction of Professor Margarita Astapenko. She beIieves that focaI infection is the triggering mechanism of the disease. As evidence she cites: (1)a survey of rheumatoid arthritic patients made by A. I. Nesterov and his collegues in which 80 per cent were found to have foci in the throat or elsewhere; arid ( 2 ) results of studies in their Institute which revealed a rise of hemolytic streptococcal antibodies ( antistreptolysin 0, antistreptokinase or antistreptococcal hyaluronidase) in 50 per cent of early cases. Given the suit- 626 CURRIER MC EWEN able infection, Professor Astapenko believes that rheumatoid arthritis occurs if the patient’s nervous and hormonal reactivity are right for it. Reactivity of the nervous system is studied by means of electroencephalography and by a number of electrophysiologic studies. Hormonal changes in reactivity are measured by altered adrenal response to corticotropin. The therapeutic regimen in this subdivision of the Institute consists of: (1)removal of any foci of infection which may be found; (2) administratiori of corticosteroids, aspirin, phenylbutazone, gold, chloroquin and dmgs affecting the autonomic nervous system (the type of the latter depending on results of electrophysiologic tests ) ; ( 3 ) physical therapy, corrective exercises and massage, and also occupational therapy promoting rehabilitation’; and ( 4 ) treatment in sanitaria. For the latter, many of the patients go to Sochi, on the Black Sea, for one or two months of sulfurated hydrogen baths and other treatment. Patients who require orthopedic surgical procedures are referred to another hospital. The “Less Common Collagen Diseases”: This unit of 15 beds is udder the direction of Professor Ugene Tareev. He, however, was away at the time of my visit and I was taken on rounds by his associate, Dr. V. A. Nasonova. During the two years since the Institute opened, they had studied approximately 30 cases of systemic lupus erythematosus, about an equal number of patients with scleroderma, and smaller numbers of patients with polyarteritis n’odosa and dermatomyositis. Dr. Nasonova considers these diseases and rheumatoid arthritis to have pathogenetic association and that probably all are due to allergic mechanisms on an autoimmune basis. Therapy is essentially the same as that in the United States. Corticosteroids are used in doses sufficient to control acute symptoms, and recently chloroquin has been added to the regimen’. Dr. Nasonova has been satisfied by her experience with corticosteroids in early cases of scleroderma. Physical Medicine and Rehabilitation: Dr. M. A. Samsonov heads this unit assisted by three other full-time physicians and a number of technicians. The staff obviously is ample for the 90 bed clinic, especially in view of the fact that many of the patients with rheumatic fever and severe collagen diseases require little of this form of treatment. Much use is made of exercises and comparatively less of ultrasonics and baths. Various devices to assist the handicapped patient are tested and devised. A mock-up of a bus is used to train patients in the use of public transportation. Laboratory of Functional Diagnosis: This unit is headed by Dr. V. F. Sisoyev. Its purpose is to assist the clinicians in the diagnosis of rheumatic diseases by means requiring special equipment. Studies performed include electrocardiography (plus vector and stereovector technics), phonocardiography, measurement of minute heart volume, electrokymography, recording of phase currents of heart action, pulmonary function tests, BMR, etc. The chief research interest is the development of improved methods of phonocardiography. The unit is excellently provided with equipment. Somewhat removed from the main laboratory for functional diagnosis is the RHEUMATOLOGY IN THE U.S.S.R. 627 Electroencephalographic Laboratory headed by Dr. E. Bronzov, which is used especially for the study of patients with rheumatic fever. Academician Nesterov finds EEG abnormalities in a majority of cases of rheumatic fever. He believes that patients with acute forms of rheumatic fever which respond well to treatment and have few recurrences, have comparatively little change in EEG. Conversely, patients with a chronic and unfavorable course have persistent and considerably changed EEG patterns. E x p e r i m t d Department This department consists of a number of laboratories devoted to research in the basic sciences as applied to rheumatology, each of which is briefly described below. Biochemistry: This laboratory is headed by Prof. Artemi Tustan’ovsky who has with him a number of junior assistants and an ample technical staff. Prof. Tustanovsky’s research is concerned primarily with the chemical and physical structure of collagen. In 1947, Professor Tustanovsky worked with Orekovich (now Director of the Moscow Institute of Biochemistry), whose research is also largely related to collagen. Tustanovsky considers procollagen identical with all forms of soluble collageni but distinct from insoluble collagen. He has described various aggregates of procollagen-colloidal suspensions, crystals and fibers-all of which can change into one another and have the same xray diffraction. Insoluble collagen, however, he found to have a different x-ray diffraction pattern. He believes that procollagen forms the outer sheath of the collagen fibril and gives the characteristic 640 A electronmicroscopic periodicity. Within is the core of insoluble collagen, which he calls collastromin and which he has described as having a periodicity of 210 A. He considers procollagen and collastromin different proteins, not only because of various physical differences but also because at early stages of embryonic development of the skin he cad find only collastromin, whereas later, procollagen appears also. He believes that the primitive mesenchymal cell makes predominantly collastromin whereas the fibroblast makes both procollagen and collastromin and that the mature fibrocyte makes chiefly procollagen. A summary of A. A. Tustanovsky’s views, in English, was published in 1959.l This laboratory is studying also the role of streptococcal antigens as well as their complexes with homologous procollagen ( as models of “autoantigens” ) in the development of various mechanisms of tissue alterations in rheumatic fever. The next aim of these experiments is the discovery of new information regarding pathogenesis of rheumatic fever and new means of active prophylaxis. Histochemistry: This laboratory is headed by Dr. (Sc. D.) G. V. Orlovskaya, whose research supplements that of Professor Tustanovsky by exploring the histochemical characteristics of conn’ective tissues in the normal state and in rheumatic lesions. Her views were reported in English in 1959.?- On the basis of these and earlier studies, she has developed the following concept of morphogenesis of valvular lesions in rheumatic fever and the formation of fibrinoid: The first visible change is mucoid swelling of the collagen fibers. This is quick- 628 CURRIER M C EWEN ly followed by disorganization' of collagen with separation of procollagen and collastromin. Paralleling these changes in the fibrils, the ground substance also undergoes disorganization. Fibrinogen and other proteins from blood then infiltrate the lesion and form abnormal complexes with collagen' proteins and mucopolysaccharides to produce fibrinoid. She has reported that the ground substance of cardiac valves is made up largely of a chondroitin sulfateprotein complex and that very little hyaluronate is present. In healing, plasma proteins are partially reabsorbed into the blood stream, but some remain and undergo hyalinization. In a later stage of hyalinization, the tissues return toward, but not to, normal. Throughout these stages the fibrocytes remain alive, and it is they and not new fibroblasts which are responsible for the reconstruction of connective tissue at the sites of disorganization. The fibrocytes round up, the nuclei enlarge, and granules of glycogen and RNA appear around the latter. Procollagen and polysaccharides are made by the fibrocytes and contribute to scarring. The procollagen has many free groups which bind apetites with resultant calcification: Also in' this laboratory, Dr. A. B. Kaplansky studies plasma cell reactions of lymphatic tissues in an investigation of antibody production. Clinical Chemistry: This laboratory group, which is headed by Prof. Anna Kvyatkovskaya, has two functions. In a well-staffed laboratory on the fourth floor, the usual chemical and clinical laboratory tests are done as requested by the clinicians. Professor Kvyatkovskaya's main personal interest, however, is the research she carries out in a separate laboratory on the second floor. Here she is studying the metabolism of tyrosine as a precursor of epinephrine, and chemical mediators of the vegetative nervous system. Pathomorphological Laboratory: Professor A. I. Strukov, who is Director of the Department of Pathology of the First Moscow Medical Institute (Medical School), serves as Scientific Consultant. The head of this unit is Candidate in Medical Sciences N. N. Grizman. Also in this laboratory group are Dr. A. A. Rogov, Candidate in Medical Sciences V. D. Almajarova and three technicians. The unit has two functions: ( 1 ) biopsies and postmortem examinations; and ( 2 ) research. Research id pathology in the U.S.S.R. has the great advantage that every patient who dies is autopsied. In this Institute the number of deaths is, of course, small with the result that only 10 or 12 postmortem examinations are done yearly. Each of these, however, is studied with the greatest care and many sections from all organs and tissues are painstakingly examin'ed using special histochemical stains as well as the customary ones. The current research program of this division has two principal directions: (1) the development of morphologic criteria of disease activity in rheumatic fever; and ( 2 ) the evaluation of the significance of histologic similarities and differences among the various collagen diseases. With regard to the former, Candidate Grizman believes that Aschoff bodies are found in both endocardium and myocardium in early stages of rheumatic fever, but that those found in specimens obtained at operations on patients thought to have inactive disease occur only in the endocardium. She doubts that the latter indicate active disease. With regard to the second area of investigation, they observe the same overlapping features which have been noted in the United RHEUMATOLOGY IN THE U.S.S.R. 629 States between rheumatoid arthritis and the “rare collagen diseases,” and emphasize the absence of Aschoff bodies in any rheumatic disease except rheumatic fever. They have, however, reported a number of instances of Aschoff bodies in the myocardium of patients with tuberculosis, but no clinical evidence of rheumatic fever.3 Biopsies of auricular appendages surgically excised at commissurotomy are examined to define morphologic criteria of rheumatic activity. These investigators suggest that the Aschoff body is not a reflection of clinical rheumatic activity but that non-specific inflammation is, Studying the functional state of cells taking part in rheumatic cardiac lesions, Dr. Rogov has investigated oxidative enzymes in fresh sections. He considers that the state of activity of these enzymes in Aschoff body cells indicates the functional activity of the latter, especially their phagocytic capacity, and also their plastic capability. Subsequently, I enjoyed the opportunity to attend a staff conference in Professor Strukov’s department at the First Moscow Medical Institute. The conference, which was attended by some 32 members of Professor Strukov’s department and of the Institute of Rheumatism, had an informal, but efficient character and was reminiscent of similar exercises in the United States. Although Professor Strukov was obviously the chief and held in great respect by the others, there was complete absence of any atmosphere of professorial infallibility and the most junior member was encouraged to express his opinion. Experimental Pathology: This was the only laboratory in the Institute which I did not have the opportunity to visit personally, and I am dependent on Dr. Rogov for a summary of the research in progress. The unit is headed by Candidate in Medical Sciences M. I. Undrintsov. Current work is along two lines: (1) attempts to induce experimental models of rheumatic fever in animals using various technics; and ( 2 ) attempts to induce tissue changes of Immunology: Doctor in Medical Sciences Vladimir Sachkov, who heads collagen-disease-type by autoimmune methods. this unit, works closely with Academician Nesterov. The laboratory under his direction does various serologic tests requested by the clinicians such as antistreptolysin-0 and antistreptokinase titrations; Waller-Rose, latex and bentonite tests; and others. Three main research projects are under investigation: (1) analysis of the above tests in various diseases; ( 2 ) studies of electrophoretic serum patterns with particular application of immune electrophoresis; and ( 3 ) the elaboration of a special diagn’osticmethod based on the identification of special antigens in the sera of patients with various rheumatic diseases. The latter was of particular interest to me and I discussed it in some detail with Mr. Sachkov who, fortunately for me, speaks English quite well. Various fractions of serum of patients with acute rheumatic fever are obtained in as pure a form as possible by starch electrophoresis and chemical means. Chickens and rabbits are immunized with these and the antisera thus obtained are the reagents used in the test. The technic of the test is as follows: 0.01 ml. of this antiserum is placed on a paper strip numbered one, 0.01 ml. of the patient’s serum on a strip numbered two, and 0.005 ml. of each of the two 630 CURRIER MC EWEN sera on a strip numbered three. Total amounts of gamma globulin are then measured electrophoretically; the mead of three parallel trials being taken. If strip three gives a percentage content of gamma globulins less than 1.5 per cent more than the average of one and two, the test is negative. A difference of 1.5 per cent or more is positive. Mr. Sachkov and Academician Nesterov had just returned from a conference on rheumatic diseases held in Prague, where this work had been reported, and I had the privilege of seeing the data presented on some of their lantern slides. The test was positive in 35 of 36 patients with active rheumatic fever but in only one of 56 patients with clinically inactive rheumatic fever. Results were uniformly negative in all of smaller groups of patients with “allergic arthritis,” “tonsillitis pre-rheumatic fever,” “chronic non-specific infectious (rheumatoid) arthritis,” and in controls consisting of patients with non-rheumatic diseases and normal subjects. Department of Organization and, Methods This unit is staffed by four physicians and several technicians. Its activities include: ( a ) the detection of cases of rheumatic fever and rheumatoid arthritis in the U.S.S.R.; ( b ) organization of programs for prophylaxis against rheumatic fever; and ( c ) improvement of the organization of the network of medical care of patients with rheumatic diseases throughout the country. This department serves as a connecting link between the Institute of Rheumatism in Moscow and public health units and practicing physicians all over the U.S.S.R. Leningrad Prior to my departure for Leningrad, Academician Nesterov gave me the names of rheumatologists he recommended I see there. These included Prof. Chernoruzky at the Institute of Internal Medicine, Prof. V. A. Valdman at the Institute of Pediatrics, and Prof. Vladimir Ioffe at the Institute of Experimental Medicine. Unfortunately, I did not succeed in meeting any of these men since all were away from Leningrad either on vacation or attending meetings. I was especially sorry to miss Professor Ioffe because I was told he is investigating possible autoimmune mechanisms in rheumatic diseases. On the other hand, I had the privilege of meeting several of the men interested in rheumatic fever at the Institute of Pediatrics. LENINGRAD INSTITUTE OF PEDIATRICS: The director of this Institute was away, but we were welcomed by Dr. Gavrilov, the Associate Director; Professor Ilya Ivanov, head of the Department of Biochemistry whom I had met previously in Washington when he was a member of the exchange group from the U.S.S.R.; and Professor Valovic, pediatrician in charge of studies on rheumatic fever. Dr. Gavrilov explained that this Institute has responsibilities in teaching, patien’t care and research. The role in teaching is especially interesting since this is one of several medical schools established some years ago for the particular training of pediatricians. Between three and four hundred pediatricians are graduated from this school each year. The Institute has 1200 beds, 880 of RHEUMATOLOGY IN THE U.S.S.R. 631 which are for children, 250 for obstetrical cases, and the remainder for adult medical cases. The various departments include all of those found in other Soviet medical schools, and the students receive instruction id all the usual aspects of medicine. However, essentially all graduates of this Institute enter the field of pediatrics. The research interests of this Institute include leukemia, rheumatism, hypertension in adults, surgical treatment of congenital heart diseases, gall bladder disease, pathology of the newborn, and sepsis an’d toxic states in children. Dr. Gavrilov estimated that a total of some 250 research projects were in progress. Following the introductory talk in the Director’s office, I spent the remainder of my time with Professor Valovic and his staff. He explained that he has 35 beds on his service, of which about four are used for patients with juvenile rheumatoid arthritis and the rest for children with rheumatic fever and rheumatic heart disease. The staff consists of 10 physicians. His views regarding rheumatic fever follow the usual concepts held in the Soviet Union. The regimen for treating rheumatic fever is essentially the same as that of Academician Nesterov, except that Professor Valovic prefers aminopyrine to salicylates. He emphasized that he has treated more than 6000 patients with this drug in doses of 1 to 2 Gm. daily for three to six weeks without a single case of agranulocytosis. In a few patients the appearance of leukopenia led them to discontinue the medication, but the white counts then’ promptly returned to normal. Prednisone is given in addition to aminopyrine for six weeks. The initial dosage level is 20 to 40 mg. daily depending on the severity of disease. Professor Valovic also spoke briefly of Russian pediatricians who have contributed importantly to the advancement of knowledge of rheumatic fever. Early among these was Sokolsky of MOSCOW, who showed in 1836-1838 that rheumatic fever can be followed by cardiac damage and after whom rheumatic heart disease is called Sokolsky-Bouillaud disease in the U.S.S.R. Professor A. A. Kisel, a Moscow pediatrician, taught that heart involvement is the most important manifestation of rheumatic fever. The pathologist, V. J. Talleleyev, wrote many important reports on rheumatic cardiac lesions including a classical monograph, “Acute Rheumatism,” in 1929. His descriptiod of the rheumatic granuloma has resulted in their being called “Tallaleyev-Aschoff bodies” in the U.S.S.R. Professor M. A. Skvortsov, still living in Moscow at the age of 82, is another pathologist who has made significant contributions in this field. I am indebted to Professor Valovic for the list of people at this Institute with an important interest in rheumatic diseases: Among the internists, Professors Valdman, Kedrov and Bulatov; among the pediatricians, Professors I. D. Garnitzkaya and himself. Kim KLEV INSTITUTE OF CLINICAL MEDICINE: This Institute, which was established in 1937 and is now directed by Professor A. L. Mikniov, is primarily concerned with research. Its departments include cardiovascular diseases, rheumatic dis- 632 CURRIER MC EWEN eases, hematology, clinical pharmacology, neurology, clinical surgery, pathologic anatomy, pathologic physiology, microbiology and work organization and methods. Studies on rheumatic diseases are carried out by Professor Isenberg in internal medicine and by Professor Tidelska in microbiology. Professor Isenberg believes that rheumatic fever can occur in infections other than those caused by hemolytic streptococci but concedes that, in fact, the latter are the most important ones. He considers rheumatic fever and rheumatoid arthritis different forms of the same disease process. His regimen for the treatment of rheumatic fever is about the same as that in Nesterov”s Institute. He is not certain whether salicylates and corticosteroids help carditis, but is hopeful. He sometimes uses aminopyrine and Butadion ( Soviet brand of phenylbutazone ), but prefers salicylates. In rheumatoid arthritis he uses corticosteroids, gold, phenylbutazone and physical medicine, but not chloroquin and rarely salicylates. Professor Isenberg stated that gout is very rare in the U.S.S.R., although it had been fairly common in Russia before the Revolution, and attributed the change to improvement in diet and living conditions. There are 275 beds in this Institute of which 115 are for patients with “rheumatism.” These are divided into three departments as follows: a service of 35 beds headed by Prof. Isenberg which is for rheumatic cardiac patients; one of 45 beds headed by Prof. Mikniov which is concerned with patients with joint disease; and one of 35 beds headed by Dozent Pirervina for patients with “neurological disabilities resulting from rheumatism.” I regret that I did not have an opportunity to visit the latter service to learn what cases were included in that category. In the three departments they have patients with rheumatic fever and rheumatoid arthritis and occasionally scleroderma, but not lupus or other collagen diseases. Professor Isenberg uses oxygen in the treatment of carditis with or without failure because his research convinces him that it improves the tissue metabolism and hence helps the myocardium. He has a research unit of several laboratories. Sukhumi Our last visit was to the attractive resort city of Sukhumi on the southeastern shore of the Black Sea. The scientific institution of outstanding interest there is the Institute of Experimental Pathology and Therapy. This Institute, which is directed by Professor B. A. Lapin, was established in 1927 as a breeding colony for monkeys and was then a unit of the Academy of Sciences. However, when the Academy of Medical Sciences was formed in 1943, it was transferred to the jurisdiction of the latter. At present, the breeding colony contains more than 1000 monkeys and apes and, in addition, research laboratories have been established in pathology, biology, experimental oncology, biochemistry, infectious diseases, “physiology of higher nervous activity,” and radiobiology. Although much interesting research is in progress, there is none concerned with rheumatic diseases. I learned that there has been no evidence of gout or of arthritis in any of the animals except for a few instances RHEUMATOLOGY IN THE U.S.S.R. 633 of transient monarticular swelling in some of the apes which were evidently of traumatic origin. Other Cities At the start of our trip I had hoped to visit Novosibirsk to observe the work of Professor G. D. Zalesky, Director of the Novosibirsk Medical Institute. Professor Zalesky has reported the isolation from patients with rheumatic fever, of a filterable virus which he believes causes rheumatic fever in combination with hemolytic streptococcal inf ections.4 However, Novosibirsk is in an area closed to tourists, and it was not possible to go there. My disappointment was less when I learried in Moscow and in Kiev that this work is looked on very sceptically by other Soviet investigators. Yerevan, the capital of the Armenian S.S.R., was included in our itinerary. Academician Nesterov had suggested that I visit the clinic of Professor A. A. Katanian there. However, poor weather so delayed our flight to that city that we had to abandon it. Although we did not visit Sochi, a word about this important spa on the northern Black Sea coast is in order. The Sochi Institute of Health Resort Studies is directed by Professor M. M. Shikhov whom many members of the American Rheumatism Association met at the International Congress on Rheumatic Diseases in Toronto in 1957. Many patients with various rheumatic diseases from all over the U.S.S.R. go to Sochi for spa therapy and rest. The greatest disappointment of my trip was the inability to visit Professor Orekovich, Director of the Moscow Institute of Biochemistry. Professor Orekovich, whom I have had the pleasure of meeting in New York on two occasions and who is one of the distinguished biochemists working on connective tissues, was unfortunately ill during our time in Moscow and could not see us. This trip made it abundantly clear to us that, in contrast to the lack of knowledge of Soviet medical research in the United States, the Soviet scientists are well aware of current work in our country. They have our journals and read them. In spite of the excellent translation service of the U. S. Public Health Service, the American investigator seldom has much knowledge of Soviet research. This is especially true in the field of rheumatic diseases. I cannot close this report without acknowledging the extreme courtesy and the warm welcome we received from all our Soviet colleagues. They not only devoted many hours to showing us their institutes and departments and explaining their research, but they made us feel that they were genuinely glad to do so. To a man they expressed the hope that more visits can be made to each other’s institutions by scientists in our two countries. For my part, I would urge that every possible effort be made to achieve this for I am confident that the better mutual understanding which can come from these visits will extend far beyond the area of science. ADDENDUM ON CLASSIFICATION OF JOINT DISEASES Since his return to the U.S.S.R., Acqdemjcian Nesterov has sent me an article which he prepared as Chairman of the All-Union Committee for the Study of Rheumatism and Joint 634 CURRIER M C E W Diseases of the Academy of Medical Sciences, entitled “The Problem of Unified Terminology of Joint Diseases.” I am much indebted to him for this article and to Dr. Emanuel Rudd, who kindly wanslated it from the Russian for me. The article cites the classification of the Committee of Experts of the World Health Organization which had been recommended for general adoption at the IX International Congress on Rheumatic Diseases. While emphasizing the importance of adopting an internationally accepted nomenclature, Academician Nesterov noted a number of points which were unacceptable to the All-Union Committee. Chief among these was the failure to classify the diseases according to a systematic plan based on etiology, pathogenesis or anatomy. In the Soviet Union, a “unified working classification of arthritides based on etiologic, pathoclinical and pathogenetic principals” had been adopted in 1938 and revised in 1951. This was again reviewed and the current one was adopted by the All-Union Committee on March 22, 1958 as follows: Working Classification and Nomenclature of Joint Diseases I. Infectious (inflammatory) polyarthritis and arthritis A. Rheumatic polyarthritis ( disease of Sokolsky-Bodllaud ) B. Diseases and disorders commonly accepted as infectious-inflammatory ( a ) Infectious arthritis with specific etiology, related to known infection: tuberculosis, gonorrhea, syphillis, sepsis, brucellosis, dysentery and also arthritis due to certain other infections ( b ) Infectious non-specific (rheumatoid) arthritis ( c ) Still’s disease ( d ) Ankylosing spondylitis ( Bechterew’s disease) ( e ) Felty’s syndrome 11. Dystrophic ( non-infectious ) arthritis A. Chronic deforming osteoarthritis ( osteoarthritis of aging, osteoarthrosis) B. Benign polyarthritis secondary to physical exertion, cooling, poor hygienic conditions of work and living C. Endocrine (hyperparathyroidism, acromegaly, myxoedema, thyrotoxicosis, menopause, etc.) D. Metabolic (gout, ochronosis, Kashin-Beck disease, scurvy, hemophilia, etc.) E. Aseptic subchondral necrosis 111. Traumatic arthritis secondary to A. Closed joint fractures B. Compound joint fractures C. Repeated microtrauma ( arthritis of vibration) IV. Arthritis associated with other diseases A. With disseminated lupus B. With periarteritis nodosa C. With dermatomyositis, scleroderma, erythema nodosum, erythema multiforme, Reiter’s syndrome D. With blood diseases (leukemia, etc.) E. With lung diseases [sarcoidosis ( Beck-Shuman’s disease), pulmonary osteoarthropathy] F. With intoxications (lead, etc.) G. With psoriasis H. With diseases of the nervous system V. Rare forms of joint disorders A. Intermittent hydarthrosis B. Serum and drug sickness C. Joint chondromatosis The Committee noted that, “in diseases of joints and also as independent manifestations RHEUMATOLOGY IN 635 THE U.S.S.R. of disease processes, one also sees damage to other structures of the locomotor system: periarthritis, fibrositis, myositis, myalgia, bursitis, tendovaginitis, etc.” The article closed with the following statement: “It is expected that in using this classification involvement of joints should be expressed in the commonly accepted terminologypolyarthritis, monoarthritis, or more precisely, arthritis of the knees, arthritis of the hip, sacro-iliitis, spondyloarthritis, periarthritis, etc. Whenever possible the characteristic process in the joint should be listed (synovitis-with effusion, exudative, serous, purulent). TOgether with joint damage, it is desirable to state in the diagnosis damage to muscles, ligaments, bursae, etc. One must specify also in the conventional way the course of disease, namely, whether acute, subacute or chTonic. The diagnosis of joint disease should, finally, be completed by evaluation of the functional state of the joint, as described by A. I. Nesterov, distinguishing three stages of functional insufficiency.” REFERENCES 1. Tnstanovsky, A. A.: Collagen and collagen fiber. Acta morphol. Suppl. 8: 17-20, 1959. 2. Orlovskaya, G. V.: Fibrinoid lesions in connective tissue. Zbid 21-23. 3. Gritzman, H. H.: 0 revmatoidnykh granulomakh v miokarde tuberkuleznykh bol’nykh. Arkhiv Patologii Moskva 12:65-72, 1950. 4. Zalesski, G. D., Vorobeva, N. N., Piro, 0. I., Shurin, C. R., Kaznacheev, V. P., Yavorovakaya, V E., Fedorov, A. I., and Mosolov, A. N.: 0 cpetzificheskom vozbuditele revmatizma. Cubsh chenie 1., Terapevticheskii Archiv 30: 3, 1958. Currier McEwen, M.D., Professor of Medicine und C h a i m n , Rheumatic Disease Study Group, N e w York University Medical Center, New Ymk, N . Y.