The Role of Russian and Soviet Scientists

In Development of Diagnosis and the General Therapy of Internal Diseases

The Russian and Soviet clinicists Mudrov, Zakharyin, Botkin, Ostroumov, Obraztsov, Strazhesko, Konchalovsky, Lang and many others made an important contribution to the development of the diagnosis and general therapy of internal diseases.

The founder of the Russian therapeutic school, Matvey Mudrov (1776-1831), assumed that disease is a result of exposure of man to un­favourable effects of the environment. Accordingly he was the first to in­terrogate the patient in order to substantiate the anamnestic method. He developed a planned clinical examination, and recording case histories. Mudrov was the first in Russia to organize practical clinical studies for students, he organized special laboratories and a museum. In the field of general therapy he followed the principle of individual approach and claimed that the patient should be treated rather than his disease. He also emphasized the great importance of hygiene.

Grigory Zakharyin (1829-1897) worked out in detail the anamnestic method of diagnosis which helped establish individual diagnosis (in addi­tion to the physical examination of the patient) in the presence of not only morphological but also functional changes in various organs. An outstan­ding French clinicist Huchard wrote: "Zakharyin's school used observa­tion, accurate anamnesis, and knowledge of aetiology, which where raised to the level of an art". Zakharyin worked at the diagnosis of tuberculosis and its classification, he described zones of hypersensitivity of the skin in diseases of internal organs. According to Zakharyin, the therapy of disease should include hygienic procedures, climate therapy, dietary treatment, and medicamentous treatment. His contribution to symptomatic therapy is ^very great; he proposed treatment with koumiss (fermented mare's milk) and mineral water.

Sergei Botkin (1832-1889) founded the physiological school in medicine and pioneered in experimental pharmacology, therapy, and Pathology in Russia. Botkin considered that a clinical experiment is a tool

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for opening the mechanism of disease development. He widely introduced the physiological and instrumental study in clinical practice. Guided by Sechenov's ideas, Botkin worked out the theory of disease development, in which the first role was given to the nervous system. This enabled him and his pupils to show the role of the nerve centres in regulation of haemopoiesis and body temperature. In the field of diagnosis, Botkin established the difference between hypertrophy and dilatation of the heart, discovered the postsystolic murmur in stenosis of the left venous orifice (which was later described as a protodiastolic murmur), described the listening points for diastolic murmur in aortic valve incompetence, was the first to diagnose thrombosis of the portal vein. Botkin pointed out for the first time the infectious aetiology of catarrhal jaundice (which was later given his name); he gave a detailed description of the disease known as Wolhynian (five-day) fever, and discovered the role of tissue destruction in the pathogenesis of fever.

Botkin believed that the main task of practical medicine is disease prevention. He was a social worker and was the first to organize out­patient and then hospital treatment free of charge. He is justly considered to be the founder of military field therapy.

Aleksey Ostroumov (1844-1906) actively fought for the connection of theory with practical medicine. He emphasized the importance of physics, chemistry and biology for the development of clinical medicine. Physiological studies by Ostroumov proved the important role the central nervous system plays in man. They were aimed at solving problems of clinical medicine. He worked out the main principles of the theory of reflex disorders in various organs due to affection of the nervous system. Ostroumov believed that variations in the course of one disease depend on the special properties of an individual macroorganism and its nervous system. He emphasized the importance of the relationships between man and the environment, and the role of hereditary factors in the pathogenesis of diseases. Ostroumov worked out in detail the clinic of early tuberculosis, balneo- and physiotherapy, indications and contraindications to sanatorium and health resort therapy in tuberculosis and nervous diseases. In Ostroumov's opinion, individual therapy, envigorating and symp­tomatic treatment should be combined with specific treatment of patients.

Vasily Obraztsov (1849—1920) was among the founders of the Soviet therapeutic school. He developed and improved methods for clinical study of patients. He devised and substantiated the method of deep sliding palpa­tion of the stomach and the intestine, and palpation of other organs. He was the first to propose direct percussion of the thoracic and abdominal organs, direct auscultation of the heart to differentiate between the gallop rhythm and the third heart sound. Together with Strazhesko, Obraztsov

gave a complete account of the clinic of thrombosis of the coronary arteries and proved the possibility of intravital diagnosis of thrombosis. He also classified enteritis as an independent clinical form.

Nikolai Strazhesko (1876-1952) was the disciple and successor of Obraztsov. He continued developing methods to study internal organs. He substantiated the principles of examination of the alimentary organs, which he described in his book "Fundamentals of Physical Diagnosis of Diseases of the Abdominal Cavity", which has remained a valuable manual for the therapist of today. His studies of the cardiovascular system enabled him to work out the teaching of functional circulatory insufficien­cy, to classify (together with Vasilenko) circulatory insufficiency, to describe various symptoms in diseases of cardiovascular system (e.g. a pistol-shot sound in complete heart block). Strazhesko described rheumatism as an infectious-allergic disease of the streptococcal aetiology, revealed special features of rheumatism and connections between rheumatism, sepsis, and endocarditis; he described the relation between cardiac asthma and angina pectoris.

Maksim Konchalovsky (1875-1942) demonstrated the importance of the syndrome approach to diagnosis of diseases and worked out the infectious-allergic theory of rheumatism; he described its clinical forms and course, and also determined indications and contraindications to blood transfusion in the clinic of internal diseases. Konchalovsky described the clinic of late chlorosis, the "tourniquet" sign in thrombocytopenia, and developed the teaching of the haemopoietic function of the stomach. Konchalovsky struggled for the union between therapy and broad pro­phylactic measures, for therapy of premorbid conditions; he developed methods for functional diagnosis, and worked at problems of employment prognostication.

Georgy Lang (1875-1948) was the first to define essential hypertension as an independent disease caused by disordered cortical and subcortical regulation; he classified diseases of the circulatory system and was the first to propose the term "myocardial dystrophy".

Lang founded a new "functional" trend in haematology which treats some diseases of the blood system in connection with disorders in the cir­culatory and haemolytic systems. He proposed a classification of liver diseases. Lang and his pupils developed methods for functional diagnosis °f cardiovascular diseases and diseases of the liver. He was the first to pro-Pose treatment of fibrillation with quinidine.

The Soviet clinicists Zimnitsky, Pletnev, Zelenin, Yanovsky, Kurlov, Shklyar, Chernorutsky, Vovsi, Myasnikov, Molchanov and many others made an important contribution to the development of internal medicine, diagnosis of diseases in particular. Many other outstanding Soviet scien-

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tists and clinicists, talented teachers continue the traditions of the Russian and Soviet medicine and work to solve many important problems of inter­nal pathology.

Soviet Public Health System: A New Stage in Medicine

Soviet medicine is based on the progressive theory of dialectical materialism. The object of Soviet medicine is to improve the health of the entire population. The work of the public health system is aimed at broad prophylactic and health-improving measures, and at rendering skilled medical aid free of charge.

The prophylactic trend is an important feature of the Soviet medicine in compliance with the tradition of the Russian clinical school. The founder of the first clinic in Moscow, Mudrov, wrote more that 150 years ago: "To take into our hands healthy people, to protect them from diseases, either inherited or threatening, and to prescribe an appropriate way of life for them—this is the most honest and trouble-free duty of the physician, since it is easier to prevent a disease than to cure it. This is the first duty of the physician". Zakharyin emphasized that "only hygiene can successfully fight diseases".

This was the challenge of the past. Now prevention of diseases, both in­fectious and non-infectious, has become the main object of Soviet medicine, which is successfully fulfilled by the Soviet public health system. The socialist public health system fights diseases according to a thoughtful plan and the results of this planned struggle are wonderful: health stan­dards of the population of the Soviet Union are among the best in the world. Improvement of the well-being of the population and the high cultural standards facilitate further development of the Soviet public health to decrease morbidity and mortality among population.

Social prophylaxis (prevention of diseases) is accomplished in the Soviet Union by the continuous growth of the well-being and the cultural level of the Soviet people. The living and working conditions are constantly improved. The quality of food is controlled by special authorities. The liv­ing conditions in large regions are improved by irrigation and other measures. The health of people is protected and diseases are prevented by a wide range of measures including the improvement of the well-being and cultural level of the population, by development of all links in the public health system, by giving medical assistance free of charge, by health educa­tion of the population, mother and child care, by development of sports, by building rest homes, sanatoria, and health resorts, and by the Soviet social security system. There are many dispensaries and special (car-

diological, gastroenterological, etc.) centres and hospitals, special depart­ments at policlinics, and sanatoria in the Soviet Union. Dispensaries are specialized centres that are responsible for the early detection of disease and give regular medical assistance to patients with chronic diseases, hospitalize patients, organize prophylactic aid at home and in industry. The number of hospitals and beds for stationary treatment of patients is continuously growing.

The Constitution of the Soviet Union guarantees protection of its citizens health. The Communist Party and the Government of the Soviet Union do their best to further improve the system of health protection and prevention of diseases among the population of the Soviet Union.

Chapter 3

METHODS

OF CLINICAL EXAMINATION OF PATIENTS

AND GENERAL SYMPTOMATOLOGY OF DISEASES

OF THE INTERNAL ORGANS

In order to arrive at a correct diagnosis it is necessary to be able to iden­tify the signs of the disease, and to reveal the appropriate changes in the pa­tient. Various methods are used to reveal and study the numerous symp­toms of the disease. These methods include questioning the patient, measuring his body temperature, and complicated techniques of examina­tion (microscopy of the formed elements of the blood, chemical studies of the bodily fluids, X-ray examination of the patient, etc.).

A healthy person does not feel any unpleasant sensations. Pain, nausea, vomiting, elevated body temperature, enlargement of certain internal organs, e.g. of the spleen, occur only in the sick, and are considered as signs or symptoms (Gk symptoma that which happens) of diseases. Some symptoms indicate changes that occur in the entire body (e.g. elevated temperature), while others (e.g. diarrhoea) may only indicate dysfunction | of a particular organ or a system, or changes in the structure of an organ (e.g. an enlarged and firm spleen).

Pain or nausea are subjective symptoms experienced by the patient. These sensations reflect objective changes that occur in the patient's body. Signs of the disease that are revealed by the physician during his examina­tion of the patient, e.g. jaundice or enlarged liver, are objective symptoms of the disease.

It is almost impossible to diagnose a disease by only one symptom. A correct diagnosis can only be established by investigating several symp­toms. Most incorrect diagnoses are the result of an insufficient examina­tion. The main requirement is therefore a thorough and systematic ex­amination of the patient. A correct diagnosis can be established if the physician follows a definite plan in his examinations.

The examination begins with an interview. The patient tells his com­plaints which often are of no less importance than a thorough objective ex­amination of the patient. Some diseases are diagnosed almost exclusively by the patient's complaints. Angina pectoris, for example, is frequently diagnosed almost entirely from the character of pain in the region of the heart. Cholelithiasis is diagnosed by attacks of pain in the right upper ab­dominal quadrant. A detailed questioning of the patient concerning the

time of the onset of the disease, its early symptoms (until the time of medical examination) is even more important in establishing a correct diagnosis. All this information is usually called anamnesis morbi, i.e. remembering the present disease by the patient, as distinct from anamnesis vitae which is the history of previous diseases of the patient. Stages of development of the present disease are traced back while collecting an anamnesis from the history of the disease as given by the patient himself and also from the information supplied by his relatives.

Another stage of examination is objective examination of the patient's condition at the present time (status praesens). This examination includes various diagnostic procedures (inspection, measuring temperature, percus­sion, auscultation, palpation, laboratory tests, X-ray examination, etc.) and reveals changes in the patient's body and deviations from normal structure and function of various organs that could not be sensed by the patient himself.

As a rule, a patient undergoes repeated examinations during his obser­vation by medical personnel. These examinations reveal subjective and ob­jective changes in the state of the patient, the disease progression, and the efficacy of the therapy given. This is information on the course of the disease (decursus morbi).

All information obtained by questioning the patient and by objective examinations, information on the course of the disease and the prescribed treatment are recorded to make a history of the case. A complete diagnosis (i.e. the main disease and the accompanying diseases and complications, if any) are given on the first page.

At the end of the history record, when observation of the patient is over, a conclusion or epicrisis should be given, where the special character of the disease and the result of the treatment should be described.