Introduction
Pathological anatomy is an integral part of theoretical and practical medicine and has its roots in ancient times. As an independent discipline, it developed slowly due to the fact that the autopsy of the bodies of the dead was prohibited for a long time. Only in the 16th century did they begin to accumulate materials on the pathological anatomy of diseases obtained during the autopsy of corpses.
Pathological anatomy is an integral part of pathology - a science that studies the patterns of occurrence and development of diseases, individual pathological processes and conditions.
In the history of the development of pathological anatomy, four main periods are distinguished: anatomical (from antiquity to the beginning of the 19th century), microscopic (from the first third of the 19th century to the 50s of the 20th century), ultramicroscopic (after the 50s of the 20th century); the modern, fourth period of the development of pathological anatomy can be characterized as the period of the pathological anatomy of a living person.
General information about pathological anatomy
The main method of pathological anatomy is the autopsy of a deceased person - autopsy. The purpose of the autopsy is to establish a diagnosis of the disease, to identify the complications that led the patient to death.
Autopsy is performed by a pathologist in the presence of attending physicians.During autopsy, the pathologist takes pieces of various organs for histological examination, and, if necessary, for bacteriological and bacterioscopic studies. At the end of the autopsy, the pathologist writes out a medical death certificate and draws up an autopsy report.
From pieces of organs, fixed in a 10% solution of neutral formalin, laboratory assistants of the pathological department prepare histological preparations. After microscopic examination of such drugs, the pathologist prepares the final pathological diagnosis and compares the clinical and pathological diagnoses. The most interesting cases and cases of discrepancies in diagnoses are discussed at clinical and anatomical conferences. Students get acquainted with the procedure for conducting clinical and anatomical conferences during the course of the biopsy-sectional cycle in the senior years.
The main method of pathological anatomy should also include the biopsy method of research. Biopsy - from the Greek words bios - life and opsis - visual perception. Biopsy refers to the histological examination of tissue pieces taken from a living person for diagnostic purposes.
Distinguish between diagnostic biopsies, i.e. taken specifically to establish a diagnosis, and operating rooms, when organs and tissues removed during the operation are sent for histological examination. Quite often, medical institutions use the method of express biopsy, when a histological examination is carried out directly during surgery to resolve the issue of the volume of surgery. Currently, the method of puncture biopsies has become widespread). Such biopsies are performed using appropriate needles and syringes by puncture of internal organs and suction of material from an organ (kidney, liver, thyroid gland, hematopoietic organs, etc.) into the syringe.
Among modern methods of pathological anatomy, the method of immunohistochemistry and hybridization in place are of primary importance. These methods gave the main impetus to the development of modern pathological anatomy; they combine elements of classical and molecular pathology.
Immunohistochemical methods (IHC). They are based on the specific interaction of human tissue and cellular antigens with specially prepared antibodies bearing various labels. Today it is not difficult to obtain antibodies to almost any antigen. By studying specific molecules, IHC allows one to obtain information about the functional state of the cell, its interaction with the microenvironment, determine the cell phenotype, establish the cell's belonging to a particular tissue, which is crucial in the diagnosis of tumors, assessment of cell differentiation, and histogenesis.
In situ hybridization (GIS) is a method for the direct detection of nucleic acids directly in cells or histological specimens. The advantage of this method is the ability not only to identify nucleic acids, but also to correlate with morphological data. The accumulation of information on the molecular structure of viruses using this method made it possible to identify foreign genetic material in histological preparations, as well as to understand what morphologists called viral inclusions for many years. GIS, as a highly sensitive method, is necessary for the diagnosis of latent or latent infections, such as cytomegalovirus, herpes infections, hepatitis viruses.
Electron microscopy. To diagnose pathological processes on the material taken during the patient's life, when necessary, electronic is used. Transmission EM is usually used to study material in ultrathin tissue sections, to study the details of the structure of cells, to detect viruses, microbes, immune complexes, etc.
EM is a laborious and expensive method and should only be used when other methods have exhausted themselves. Most often, such a need arises in oncomorphology and virology.
Anatomical period (from antiquity to the beginning of the 19th century)
The origins of anatomy are lost in the darkness of centuries. Images of people and animals, made in the Stone Age, convey the external forms of the body in rest and movement, in them the signs of the male and female sex are highlighted and accentuated. On the wall of the Pindal cave in the Pyrenees (Spain), an image of a mammoth was discovered, in the center of which a primitive artist painted a heart. It can be assumed that in primitive society, when assisting the wounded and when butchering the carcasses of killed animals, some ideas arose about the internal structure of the body, but they were fragmentary and unclear.
The first targeted observations in the field of human anatomy began to be carried out in the era of ancient civilizations. So, in China at the end of the 4th century BC. NS. the governor of one of the provinces handed over to the doctors the corpses of forty decapitated people, allowing them to be dissected in the interests of science. The ancient Chinese medical treatise Huangdi Nei-Jing provides data on the density of the heart, liver, lungs and other organs, the capacity of the stomach and bladder, the length and capacity of the intestines, etc. The lack of knowledge about the functions of organs was filled with speculative ideas. The ancient Chinese believed that the heart was the first of the entrails subject to fire. The liver was called the mother of the heart and the abode of the soul, and the stomach and spleen were recognized as the sons of the heart. Courage was associated with the gallbladder. It was believed that different organs are connected by channels (meridians) in which pneuma (qi) circulates - the energy of life, which includes two principles: male Yang, active and hot, and female Yin, passive and cold. In the III-II centuries. BC NS. autopsies were prohibited and the development of anatomy in China was suspended.
In ancient India, there was no prohibition on opening corpses; the maceration method was used to study them: the body had to lie for seven days in a stream in a basket of willow twigs, and then skin was removed from it with the help of tree bark until the organs underneath were revealed. The first ideas of the ancient Indians about the structure of man were reflected in the myth of the first man - Purusha, from whose body parts the universe was formed. In Ayurveda, ancient Indian written compositions, it is indicated that a person consists of seven shells, three hundred bones, three liquids, nine hundred ligaments and ninety veins starting at the nails. The navel was considered the center of life, from which the vessels that carry blood, water and mucus originate.
In ancient Egypt, the custom of embalming corpses contributed to the accumulation of anatomical knowledge. Ancient Egyptian doctors knew only individual internal organs - the heart, brain, liver, and also blood vessels. The main organ was considered to be the heart, from which 22 vessels were believed to extend to all parts of the body. Naturalists and doctors of Ancient Greece significantly enriched knowledge of the structure and functions of the body. In explaining the phenomena of life during this period, materialistic and idealistic currents already collide.
In the 5th century BC, the physician Alcmeon of Croton was the first anatomist to point out the need to dissect human corpses to study anatomy; he discovered the nerves that connect the eye and ear to the brain, and believed that the brain is the organ of sensation and thought. The great physician of antiquity Hippocrates (460-377 BC) and his students have works on anatomy: "On Anatomy", "On the Heart", "On the Glands", anatomical data are found in the writings ("On Wounds head "," About fractures ", etc.). At that time, arteries and veins were already distinguished, and it was believed that blood flows through the veins, while arteries were considered as tubes carrying air. In the heart, a ventricle, “ears” (atria), openings and surrounding “membranes” (valves) were distinguished. Various white fibrous formations, including tendons (hence the term "aponeurosis"), were called nerves. Hippocrates was the first to describe the structure of the bones of the skull, highlighting in them a sponge-like "diploe". The largest natural scientist and philosopher of ancient Greece, Aristotle (384-322 BC) is considered the ancestor of comparative anatomy, zoology and embryology. He performed vivisections, observed the development of a chicken embryo and found in it a "jumping red dot" - the rudiment of the heart. He was the first to call the main artery of the body the aorta. At the turn of TV-III centuries. BC NS. the cultural center of the ancient world was Alexandria. The famous doctors Herophilus (born 304 BC) and Erasistratus (300-250 BC) worked there, who made a great contribution to anatomy. They dissected human bodies. Herophilus knew the ventricles of the brain and its membranes, the duodenum, and the prostate gland. Erasistratus carried out experiments on animals and found that nerves are motor and sensory. He was the first to speculate about the anastomoses between the small branches of the vessels.
After the conquest of Alexandria by the Romans, the center of the cultural life of the ancient world moved to Rome. A prominent place in the history of anatomy belongs to the scientist and physician Claudius Galen (131 - approx. 200 AD), in whose works the anatomical and physiological data of that time are most fully and systematized. The main work of Galen, "On the Purpose of Parts of the Human Body" (De usu partium), has been translated into Russian. Galen proposed a classification of bones, described many muscles, blood vessels and nerves, internal organs, and parts of the brain. He introduced the anatomical names that have survived to this day (diaphysis, pineal gland, platysma, masseter, cremaster). At that time, there was already a ban on the autopsy of human corpses, and Galen studied anatomy on pigs, monkeys and some other animals. Therefore, much in his descriptions of human anatomy was erroneous. Galen explained the structure of organs from teleological positions, based on their purpose, "benefits" for the body. Galen's idea of the movement of blood in the body, which lasted until the discovery of blood circulation in the 17th century, also did not correspond to reality.
The collapse of the Roman Empire and the transition from a slave formation to a feudal one in European countries led to profound changes in the spiritual life of society.
The period of the Middle Ages, which lasted more than 13 centuries, is characterized by the dominance of Christian ideology, the "spiritual dictatorship" of the church, scholasticism, and the rejection of the study of nature. In the field of anatomy, Galen became the officially recognized authority, whose works were declared infallible. The study of the human body has come under strict prohibition as a "sinful" pursuit. A new center of culture arose in the Middle Ages in the East, in the Arab Caliphates and the states of Near East and Central Asia that formed after their collapse. The greatest flourishing of science, including medicine, in these countries falls on the IX-XI centuries. However, Islam, like Christianity, did not allow autopsy, and therefore the doctors of the Arab world contributed little to the anatomy. In the famous "Canon of Medicine", which was written by Ibn Sina (Avicenna; 980-1037), the anatomical data are given mainly according to Galen. The doctor from Cairo, Ibn-an-Nafiz, who compiled in the XII century, deserves mention. "Anatomical commentary on the Avicenna canon", anticipating in it the discovery of the small circle of blood circulation.
Anatomy resumed only in the late Middle Ages. In the XIII-XIV centuries. universities are opening in Western Europe and medical education is expanding. The need for the anatomical training of doctors is becoming more and more acute. The pursuit of the study of the human body gradually overcomes religious prohibitions. Students steal corpses from cemeteries and gallows. Church authorities are beginning to allow the study of anatomy, but their strict regulation remains for a long time. So, when an independent medical faculty was formed in Bologna, the doctors took an oath to the rector, elected by them, that they would open only corpses acquired in an honest way, because the delivery and payment of corpses was the responsibility of the students themselves. The student had the right to be present only 2 times at the autopsy of a man and once at the autopsy of a woman. In 1315, Mondino dea Luzzi (1275-1326), who taught at the University of Bologna, dissected two female corpses and wrote a book on anatomy, which served as a guide to students for the next two centuries. This book presented data mainly on the viscera. Mondino refrained from describing a number of organs, including the bones of the skull, so as not to be accused of a "sinful" occupation. In universities in other countries, autopsies began to be practiced much later: in Montpellier (France) in 1376, in Vienna in 1404, in Edinburgh in 1505, in London in 1540, in Cambridge in 1564, in America in 1533, in Japan in 1754
In the 16th century, they began to accumulate materials on the pathological anatomy of diseases obtained during the autopsy of corpses. In 1507, the first well-known modern historiography's pathoanatomical treatise by Antonio Benevieni "De abditis nanniellis as miranlis morborum et sarationum causis" was published in Florence, based on the material of 20 autopsies. The author described in it a total of 170 different pathological changes in organs.
After A. Benevieni, dozens of original works were published in Europe in the 16th century. By the end of the century, it became necessary to generalize them, which was done by the Italian Marcello Donato ("De medicina historia mirabilis", 1586).
The most famous pathological treatises of the 17th-18th centuries are as follows:
1. Teophil Boné (Bonetus) (1620-1689) - "Sepulchretum anatomicum sive anatomica practica ex cadaveribus morbo donatis" (1679) - a book that included a description of almost 3 thousand autopsies.
2. Giovanni Batista Morgagni (1682-1771) - "De sedibus et causis morborum per anatomen indagatis" (1761) - the work is based on the results of 700 autopsies.
3. Joseph Lietot (1703-1780) - "Historia anatomica medica" (1767).
Pathological studies were also carried out by A. Vesalius, W. Garvey, G. Fallopius, B. Eustachius, F. Glisson, F. de la Boe (Silvius) and many others.
The formation of pathological anatomy, like other branches of modern medicine, was facilitated by the worldview revolution of the Renaissance and Reformation.
In the 19th century, pathological anatomy had already gained a strong position in medicine. Departments of pathological anatomy were opened in Berlin, Paris, Vienna, Moscow, Petersburg. The representative of the Viennese school K. Rokitansky (1804-1878), based on his vast personal experience (30,000 autopsies in 40 years of dissecting activity), created one of the best manuals on pathological anatomy at that time. K. Rokitansky was the last representative of the theory of humoral human pathology that had dominated for centuries, which had no scientific basis.
Microscopic period (from the first third of the 19th century to the 50s of the 20th century)
In the middle. XIX century. the development of pathology took place in a struggle of two directions; humoral (from Latin humor-moisture, liquid), rooted in the philosophical teachings of the ancient East and ancient Greece, and appeared later, solidarity (from Latin solidus - dense, solid), the first ideas about which were developed by Erasistratus and Asclepiades. the humoral direction was a Viennese pathologist, Czech by nationality Karl Rokitansky, a member of the Vienna and Paris Academies of Sciences. In 1844 he created the first department of pathological anatomy in Europe. His three-volume Handbook of Pathological Anatomy, based on more than 20,000 autopsies performed using macro- and microscopic examination methods, has gone through three editions and has been translated into English and Russian. Rokitansky believed that the main reason for the painful changes was a violation of the composition of body fluids - dyscrasia (a term of ancient Greek doctors). At the same time, he considered the local pathological process as a manifestation of a general disease. Understanding the disease as a general reaction of the body was the positive side of his concept.
Short description
Pathological anatomy is an integral part of theoretical and practical medicine and has its roots in ancient times. As an independent discipline, it developed slowly due to the fact that the autopsy of the bodies of the dead was prohibited for a long time. Only in the 16th century did they begin to accumulate materials on the pathological anatomy of diseases obtained during the autopsy of corpses.
Pathological anatomy is an integral part of theoretical and practical medicine and has its roots in ancient times. As an independent discipline, it developed slowly due to the fact that the autopsy of the bodies of the dead was prohibited for a long time. Only in the 16th century did they begin to accumulate materials on the pathological anatomy of diseases obtained during the autopsy of corpses.
Pathological anatomy is an integral part of pathology - a science that studies the patterns of occurrence and development of diseases, individual pathological processes and conditions.
In the history of the development of pathological anatomy, four main periods are distinguished: anatomical (from antiquity to the beginning of the 19th century), microscopic (from the first third of the 19th century to the 50s of the 20th century), ultramicroscopic (after the 50s of the 19th century); the modern, fourth period of the development of pathological anatomy can be characterized as the period of the pathological anatomy of a living person.
The emergence of pathological anatomy
The beginning of the formation of pathological anatomy is rightly attributed to the 16th century, when they began to investigate, or rather, actively identify and describe "organic damage to the animal body", and the first "notes on the anatomy of diseased organs" appeared in the medical literature.
The number and quality of such "remarks" increased with the increase in the number of autopsies performed for demonstration and research purposes, as the formation and development of a new anatomy. In the writings B. de Carpi and A. Benevieny, A. Vesalius and G. Fallonia, R. Colombo, B. Eustachia and other anatomists of the 16th - first half of the 17th centuries, one can find descriptions of the pathomorphological findings discovered by them during autopsies. This, apparently, gave rise to Russian researchers studying the history of pathological anatomy to associate its origin not so much with the emergence of a new anatomy and the rapid development of methodology and methods of morphological research, but with the activity of anatomists of the 16-17 centuries to identify and describe individual " organic damage to the animal body ”. One cannot agree with this position, since it was the methodology and method of morphological research developed by the founders of the new anatomy that served as the foundation on which the building of pathological anatomy was gradually built.
Firstly, the founders of the new anatomy established the boundaries of the normal structure of parts of the human body, without exact knowledge of which the identification and study of morphological changes would be impossible in principle. Secondly, it is precisely with the activities of anatomists of the 16-17 centuries, who studied not only the structure, but also the "purpose" of organs and parts of the human body, that the substantiation of the position of the inextricable connection of structure and function is connected - a position that largely predetermined the gradual turning of doctors to research clinical and anatomical correlations, which provoked them to search for and establish a connection between the deviations in the "dispatch" of organs observed in the clinic and the morphological changes found on autopsies. Finally, thirdly, it was in the depths of the new anatomy that the basic rules for conducting autopsies were developed and the foundations of the sectional research method were laid.
Apparently, A. Benevieni should be considered the author of the first work, specially devoted to the description of the pathomorphological findings that he found during the autopsy (A-Benevieni. De abditis nanniellis as miranlis morborum et sarationum causis, -Flor., 1507) .. In the work of A. Benevieni described 170 such finds, and also contains "some important notes about gallstones, about an abscess of the mesenterium (mesenterium), about the skyr of the stomach, about polyps, etc."
As for the pathomorphological findings of the anatomists of the 16-17 centuries, they, according to the apt expression of I.P. Frank, who did a lot to promote and develop pathological anatomy, were almost exclusively "collections of curiosities" which, at best, could serve "only a simple divertissement for the idle audience. "
It is difficult to argue with IP Frank's assessment. The emergence and initial stages of development of the new anatomy were not directly related to the requests and needs of practical medicine. It arose as a result of the desire of the Renaissance man to know the structure of the human body and the interaction of its parts, the internal organization of a being created in the image and likeness of God, to reveal the great secret of true harmony that exists thanks to the divine inspiration of the Creator.
The harmony of the structure and movement of the human body became the standard of beauty for the Renaissance man. It is no coincidence that the revolution in anatomy was prepared not so much by doctors as by painters and sculptors who, more than a century before Vesalius, broke with the traditions of a flat, static image of a person in order to show him in life, in motion, in joy or in suffering.
Many anatomists wrote about the cognition of the wisdom of the Creator as a stimulus and, at the same time, the most important task of the new anatomy until the end of the 18th century. “Various investigations of the body, the harmony of which we constantly proclaim and which is completely unknown to man himself,” wrote A. Vesalius in the preface to “Epitome,” which we are surprised " (Vesalius A. Epitome -M., 1974, -C.22.).
Of course, the founders of the new anatomy and their followers, who, as a rule, combined anatomical studies with practical medical activity, were aware of the importance of knowledge of the "structure and purpose of parts of the human body" for medicine. But in the conditions of the dominance of speculative theories in pathology, this knowledge could not be in demand and master the mass medical consciousness. Therefore, the various deviations in the structure of organs and body parts that were encountered attracted the attention of the first "testers of human nature" in the very last place, and they recorded in their works mainly those of them that boggle the imagination: ugly bone fusion after fractures, gross deformities of the joints , huge stones in hollow organs, large tumors and cysts.
It is no coincidence that F. Bacon pointed to the insufficient attention of doctors to pathomorphological findings, urging them to thoroughly study, analyze and generalize the "traces and imprints of diseases" and "injuries caused by these diseases" found during autopsy, since "the real culprit of the disease may not be" humores ", But" the very structure of an organ. " "But until now," wrote F. Bacon in 1623, "all this variety of phenomena is considered in anatomical studies from case to case, or is generally passed over in silence." (Bacon F. On the dignity and augmentation of sciences // Bacon F. Works in 2 volumes.-T.I.-M., 1977.-P.306.).
But anatomists, especially of the 16th century, lacked not only a motive, but also a real opportunity to record and describe pathomorphological phenomena that are really significant for practical medicine. This was primarily due to the peculiarities of the cadaveric material they used, which were mainly the bodies of executed criminals or, as W. Harvey rightly pointed out, "corpses that belonged to healthy people."
The abnormalities in the structure of the most important organs and parts of the body found at autopsies continued to serve as an object of entertainment for the "idle public", replenishing various Kunstkamera, until autopsies began to be undertaken on the initiative of doctors and professors of practical medicine specifically for the purpose of identifying and studying "organic damage" until the object of research was the corpses of people who died from diseases, and not on the gallows or under the executioner's ax. The initial conviction of internists that a disease leads to various changes in the internal environment of the body prompted them to use the achievements of anatomy in order to try to establish the causes of death of specific patients and to determine what damage to internal organs and body parts is caused by this or that disease.
And although until the end of the 18th century, few doctors were able to overstep the corporate disregard for the practice of "handicrafts" and ventured with a section knife in their hands "rummaging through hospital corpses, and ... in an instructive way to handle the remains of illness and death ..." (CIAM. - F.459. - Op.1.-D.2648.-L.41ob.), already the first series of autopsies of those who died from diseases brought many important discoveries, the main of which was the discovery of the relationship between clinical symptoms observed during the patient's life and those found during autopsy of "organic lesions".
In the Russian historical and medical literature, the opinion is expressed that the idea of a correlation between the symptoms of diseases and morphological changes in organs was first discovered in the famous work "De sedibus et causis morborum per anatomen indagatis" ("On the location and cause of diseases identified by an anatomist", 1761) of the Padua professor J. B. Morgagni... However, the surviving documentary sources indicate that this idea not only existed at the turn of the first and second half of the 17th century, but was actively developed. “In my medical anatomy,” wrote, for example, W. Harvey to the dean of the medical faculty and professor of anatomy at the University of Paris J. Rioland (junior), organs in terms of volume, structure, consistency, shape and other properties in comparison with their natural properties and characteristics, and to what varied and remarkable ailments these changes lead. For as the dissection of healthy and normal bodies contributes to the success of philosophy and sound physiology, so the study of sick and thin subjects contributes to philosophical pathology. "
In the 17th century, W. Harvey was far from the only doctor who sought to identify the connection between the clinical symptoms of various diseases and the morphological changes found on autopsies. N. Van-Tulp described the clinical and morphological picture of cystic drift and bladder cancer, recognized during the life of the patient on
the basis of the detection of a vesicourectal fistula, J. Wepfer established the relationship of ruptures of aneurysms of small arteries of the brain with the clinical picture of "stroke", F. Glisson described bone changes in rickets, F. de la Boe (Silvius) and R. Morton as a result of numerous autopsies of those who died from consumption, tuberculous seeding of the lungs was revealed. Finally, in 1676, a work by the Swiss doctor T. Bone"Sepulchretum S. Anatomia practica ex cadaveribus morbo donatis" ("Morgue, or Practical anatomy based on autopsies of patients"), in which more than 3000 autopsies performed by T. Bone and his predecessors were collected and compared with the data of case histories.
Although the author of the most extensive essays on the history of pathological anatomy in Russian literature, Yu. V. Gulkevich, gave a sharply negative assessment of the work of T. Bone, the publication of "Sepulchretum ..." should be considered a milestone event in the history of the formation of pathological anatomy. It was the work of T. Bonet that turned out to be the first work in the history of medicine in which significant material was used to substantiate the connection between the symptoms of diseases and the morphological changes found during autopsy, and moreover, the statement usually associated with the name of JB Morgagni was expressed about the existence of a "place of illness." in the human body. "The lesions inherent in any body," wrote T. Bonet, summing up the results of his research, "determine, if not the cause, then at least the location of the disease and, possibly, its nature."
It would seem that T. Bonet did everything: the presence of clinical and morphological correlations was not only traced by him on a large number of observations, but also supported by the idea of the existence of a "place of disease" in the human body. Moreover, the above text reads the thought expressed in the form of an assumption about the primacy of morphological lesions in relation to the external manifestations of the disease observed by the doctor - the symptoms of the disease. This assumption was not substantiated in any way and was hardly noticed by contemporaries. But it testifies to the dissatisfaction of a thinking and well-educated morphologist and doctor with traditional ideas about the essence and development of the disease and, as it were, expresses doubt about the infallibility of the dogmas of medical thinking that have developed over the centuries.
The doctor, on the other hand, thought in terms of the categories of specific diseases, which, like today, needed to be diagnosed and effectively treated. At the same time, the only instrument of medical analysis, or, in modern terms, sign factors, were the symptoms of the disease detected by the doctor on the basis of a survey and examine the patient. Some of the most significant and striking symptoms or a combination (complex, aggregate) of the most common symptoms together were considered as independent nosological forms. The nosological systems served as a kind of matrices on which the detected symptoms were superimposed, which corresponded to the establishment of the diagnosis.
“A clinical doctor,” wrote IV Varvinsky, a professor at the Moscow University Hospital Therapeutic Clinic, characterizing the diagnostic search algorithm for doctors of the 17-18 centuries, “... having examined a patient, combining seizures into a whole, he is looking for a form similar to the observed one in the nosological system; if it finds it, diagnosis morbi is over; if not, it constitutes a new form of the disease. The more attentive the physician is to the phenomena he observes, the more deeply he follows the changes taking place in the sick organism, the more often he fails to find in the system a form that perfectly corresponds to the one he is observing, the more often he is forced to insert new forms of diseases into the system.
With this approach to identifying nosological forms, the data obtained as a result of pathomorphological studies presented information of secondary importance to doctors. In order to "combine into a disease" another relatively frequent "group of seizures", knowledge of morphological changes was not required. The autopsies of the dead, although they were undertaken to establish the cause of death, did not serve as a means of verifying the correctness of the diagnosis made during life. The task was to identify the extent of damage caused by an already known (diagnosed during life) disease, as well as to search for and detect damage associated with clinical symptoms, on the basis of which this diagnosis was made. At the same time, neither in the event that such injuries could be detected, nor in the event that morphological changes were detected that could in no way be associated with the pathognomonic symptoms for this disease, the revision of the lifetime established diagnosis, as well as the introduction of a new "form" into the "nosological system" disease ”was not carried out. The absence of damage was explained by the functional ("dynamic") nature of the disease; detection of injuries that do not correspond to the main symptoms of the disease that the deceased suffered from, either as a consequence of postmortem changes, or the development of complications, or was not explained at all.
Up to the beginning of the 19th century, in the mass medical consciousness, pathomorphological changes were not of a symbolic nature, were not considered as signs of the disease. The results obtained during the autopsies, at best, could force some adjustments to the existing theoretical explanations of the origin of individual "seizures", as happened, for example, in the case of "apoplexy". Before publication J. Wepfer dominated the point of view that "stroke" develops as a result of the accumulation of viscous mucus in the vessels of the brain. J. Wepfer, as already mentioned, on the basis of autopsy results showed that the cause of the "blow" was a cerebral hemorrhage caused by rupture of aneurysms of small arteries, which required doctors to search and build new speculative concepts of the causes of this disease. For the first time, the question that the signs of diseases are not clinical symptoms, but the underlying morphological lesions and that when identifying "forms of diseases" it is necessary to take into account the morphological data first of all, was raised by JB Morgagni.
J. B. Morgagni- a textbook personality: his name can be found in any textbook on the history of medicine and pathological anatomy, his priority as the founder of pathological anatomy is recognized by everyone.
M. Bichat, J. Corvizar, R. Laennec referred to JB Morgagni as the supreme authority in matters of "the anatomy of a sick organism". K. Rokitansky considered "Dc sedibus et causis morborum ..." not only "for all ages a model ... in the choice of material, wealth and order of presentation", but also "an example of methods and originality."
Thanks to J. B. Morgagni, R. Virkhov pointed out, "a new science, later called pathological anatomy" appeared, which became "the basis of pathology in general, and medicine rose to the rank of natural science"; “... only after Morgagni,” asserted R. Virkhov, “the clinic reached its true value. It is safe to say that it was only thanks to Morgagni that the dogmatism of the old schools was finally broken. This was the beginning of a new medicine. ”
"With the publication of" De sedibus et causis morborum ... "- writes the modern historian of pathology E. Losh, - ... pathology as a science has entered a period of new and rapid development." Other authors also appreciated the contribution of JB Morgagni to the development of medicine no less complimentary. At the same time, even from the writings of the most authoritative, most venerable historians of medicine and pathologists, it is not easy to understand what exactly was the revolution made by J.B. Morgagni in medicine, and in clinical material.
The overwhelming majority of researchers pointed out and point in this regard to the fact that JB Morgagni formulated and proved the position of the presence of correlations between the symptoms of diseases and the "organic damage" found on autopsies and the idea of the existence of a "place of disease" in the human body. But these ideas on their own arose and were developed before J. B. Morgagni: the presence of clinical and morphological correlations was known at least as far back as W. Harvey, and the idea of the existence of a "place of disease" was expressed by T. Bonet six years before birth J. B. Morgagni.
How, then, does the work of JB Morgagni differ from T. Bonet's "Sepul-chretum ..." The completeness of the description of individual epicrises and the thoroughness of their scientific processing? But in this case, apparently, it is more correct to say that the huge and perfectly processed material presented in "De sedibus et causis morborum ..." served as the final proof of the presence of clinical and morphological correlations and the existence of a "place of disease." This is a huge merit, but it cannot be called a coup or a methodological breakthrough.
Meanwhile, there was a methodological breakthrough, and it was thanks to him that the provisions on clinical and morphological correlations and on the existence of a "place of disease" became in the hands of the followers of J. B. Morgagni a powerful tool for revising the foundations of private pathology and, above all, nosological systems, for the introduction and development of new methods. diagnostics, it was thanks to him that the clinical and anatomical direction in medicine subsequently arose.
Pathological anatomy and pathology in the first half of the 19th century
"De sedibus et causis morborum per anatomen indagatis" by JB Morgagni received a wide response in the medical world. Following the methodological approach proposed by J. B. Morgagni, many doctors at the end of the 18th century made attempts to revise the existing nosographies, proceeding from the fact that the true signs of diseases are not the symptoms of the disease, but the pathomorphological changes found on autopsies. However, very soon they faced two
surmountable problems, which somewhat cooled the ardor of the "awkward nature testers", and even made skeptics doubt the fairness and validity of JB Morgagni's ideas.
The first consisted in the impossibility, on the basis of the static picture of pathomorphological changes revealed during autopsy, to explain all the diversity, and most importantly, the dynamics of the development of symptoms observed in the clinic. The second - in the absence of any strict criteria, which made it possible in each case to separate pathomorphological changes specific for a given disease from accidental or postmortem changes.
The solution to these problems is associated with the brilliant discoveries made in the early 19th century by French clinicians and natural scientists. - M. Bichat, J. Corvisard, R. Laennec and etc.
Firstly, as a result of numerous autopsies of the deceased in Parisian hospitals, the well-established idea that only the morphological picture of death can be studied with the help of pathological anatomy. On the basis of numerous observations, it was possible to separate the concepts of "death" and "illness", which were previously considered as successive stages of a single process. Attention was drawn to the fact that death can occur not only as a result of the development of the disease, but also from accidental causes that are not related to the disease, for example, from an overdose of drugs, and in this case, the picture of morphological lesions found at the autopsy does not reflect the terminal stage of the disease, but or from the stages preceding it, both progressive and regressive development of the pathological process. This discovery made it possible, as they say, to "revive" the corpse, to formulate an approach to the study of the dynamics of morphological changes in various diseases and thereby provided an opportunity to establish the correspondence between the morphological and clinical picture of diseases.
Secondly, thanks to the percussion revived by J. Corvisard and auscultation invented by R. Laennek, doctors have at their disposal an unprecedented opportunity to identify and study the dynamics of morphological damage to some organs and parts of the body during the patient's lifetime.
Thirdly, representatives of the first generation of French clinicians established and described in detail the main postmortem processes occurring in corpses, and thereby created opportunities to accurately determine which injuries found at autopsy were due to illness, and which were already after death of the patient.
Fourthly, and this is mainly the merit of M. Bish, it was established that the organs and parts of the human body, with all the uniqueness of their structure, consist of the same tissues, and that the disease usually affects not the entire organ, but only any of its constituent tissues, and that the painful process in a particular tissue will develop according to the same principles, regardless of which organ is a component of this tissue. These three outstanding discoveries by M. Bish gave a colossal impetus to the development of the ideas of J. B. Morgagni. Soon after the "division", for example, the heart into its constituent tissues were isolated into independent nosological forms and endocarditis and pericarditis were described in detail, which was out of the question under the conditions of a spontaneous approach to the knowledge of diseases.
A direct consequence of these outstanding scientific achievements were the classical clinical and anatomical studies of R. Laenneck in the study of pulmonary emphysema, bronchiectasis, pleurisy, pulmonary tuberculosis, cirrhosis of the liver, as well as the early works of F. Brousset, who aimed at the holy of holies of pathology of the 18th century - the doctrine of fevers , traditionally considered common dynamic diseases, to the study of which the anatomical research method is not applicable.
"If we exclude some feverish and nervous suffering," wrote, for example, M. Bisha, "then everything else belongs to the field of pathological anatomy." But his student F. Brousset dared to find the morphological substrate of fevers with a section knife in his hands.
The first object of his search, he chose the so-called essential, or "flying", fevers, drawing attention to one previously unnoticed contradiction: in all nosographies, without exception, the names of various organs and parts of the body appeared in the names of many fevers ("intestinal fever", " gastric fever "," cerebral fever ", etc.). If the fever is "cerebral", argued F. Brousset, then it can no longer be considered essential, and vice versa, if the fever is essential, then it cannot be called "cerebral".
Trying to understand this contradiction and being a consistent supporter of the ideas of M. Bish and the anatomical approach to the knowledge of diseases, F. Brousset set himself the task of establishing whether there are any specific injuries in the corpses of persons who suffered from various types of fevers during their lifetime.
In fairness, it should be noted that F. Brousset was far from the first who tried to answer this question. Even JB Morgagni undertook a series of such studies, but was unable to find during the autopsy of the dead from "severe fevers ... anything that may correspond to their severity." “To such an extent it is hidden to be discovered,” he wrote in “De sedibus et causis morborum ...”.
Knowing about the failures that befell J.B. Morgagni and his other predecessors, F. Brousset did not look for injuries, the scale of which would correspond to the severity of the fevers, but, having adopted the “tissue principle” of M. Bichat, compared with the clinical picture of any fevers, even the most insignificant, morphological deviations found during autopsy. The results obtained exceeded all expectations: it was possible to establish that the severity and features of the clinical course of fevers are directly dependent not so much on the scale of the lesions, but on their localization and, in particular, on what tissue is damaged. So, during the autopsy of the dead from fevers, characterized by a "strong temperature jump", "impaired nervous functioning", "secretion disorder, and sometimes muscle disorders", almost always found "inflammatory damage to tissues rich in capillaries" (pulmonary parenchyma, pia mater ); and a completely different clinical picture corresponded to damage to the "thin membranes" ("tissues weakly penetrated by the capillary network").
This discovery, made by F. Brousset in 1816, made a great impression on the scientific medical world. Fevers began to be spoken of as diseases accompanied by morphological damage. But F. Brousset immediately went further. He reminded his colleagues that at the beginning of the 18th century G. Boerhaave and G. Stahl directly pointed out that fevers are not diseases, but signs of resistance to disease, signs that the body, according to G. Stahl, “some kind of disease-causing matter is trying or cure, or remove. "
Fever, echoed G. Stahl G. Boerhaave, - "a disease of life, which tries to repel death." Reminded F. Brousse and the etymology of the word "fever". Februe - the annual celebration of the cult purification; februo (-atum, -are) - perform cleansing rituals, ritually drive away the shadows of the dead from the house. Having analyzed from these positions the results of their clinical and anatomical observations. F. Brousset came to the conclusion that fevers represent a generalized response to "inflammatory damage" to various tissues of the body.
The famous French clinician J.-B. Buyo. And it really was almost a revolution. It seemed that the building of the former pathology was about to collapse completely, however, contrary to the existing tradition, to consider the history of medicine in the 18-20 centuries. as a continuous process of progressive development, it has survived.
An analysis of textbooks and manuals on both general pathology and private pathology and practical medicine of the first half of the 19th century shows that the achievements of pathological anatomy and the results of the use of the anatomical method of studying diseases did not force doctors and pathologists to abandon either their previous views on the disease or the established approaches. to their selection.
So, for example, the textbooks of A. F. Gekxr "Pathology, or the Science of the diseased state of the human body" (1811), I. Frank "The basis of pathology according to the laws of the theory of excitement" (1812), G. V. Konsbrukh "The initial foundations of pathology" (1817) and FK Hartman's "General pathology" (1825) show that general pathology has retained its structure unchanged, which included three main sections - etiology, symptomatology, nosology, and their content. At the same time, the fact that such a section as symptomatology remains in the structure of general pathology is especially indicative.
If we are guided by the logic of a modern doctor, then the recognition by pathologists of the fact that the signs of diseases are not symptoms, but morphological lesions found at autopsy, should inevitably lead to the displacement of this section from the general pathology and its replacement by pathological anatomy. But in reality this did not happen. "Some wanted," GV Konsbruch directly pointed out, "to classify Pathological Anatomy as Pathology, which, through cadaveric dissection, reveals the signs of altered or destroyed organs." However, the author continued further: "Pathological Anatomy often delivers results that were not at all, or at least in doubtful connection with the noted disease: and therefore they do not have a great value for Pathology, or they are still misleading."
In the middle of the 19th century, the greatest influence on the development of pathological anatomy was exerted by the works K. Rokitansky, in which he not only presented changes in organs at various stages of the development of diseases, but also clarified the description of pathological changes in many diseases.
K. Rokitansky was the last representative of the dominant for centuries theories of human humoral pathology, which had no scientific basis.
In 1844 K. Rokitansky founded the Department of Pathological Anatomy at the University of Vienna, created the world's largest pathological museum. The name of K. Rokitansky is associated with the final separation of pathological anatomy into an independent scientific discipline and medical specialty.
R. Virkhov and the reform of pathology in the second half of the 19th century
The turning point in the development of pathological anatomy and all medicine can be considered the creation in 1855 by a German scientist R. Virkhov (1821—1902) the theory of cellular pathology.
Using the discovery by Schleiden and Schwann of the cellular structure of organisms, he showed that the material substrate of the disease is cells. Pathologists and clinicians around the world have seen great progress in the cellular theory of pathology and have widely used it as the scientific and methodological basis of medicine. However, it turned out to be impossible to explain all the complexity of the pathological processes that arise during the disease by cellular pathology alone. Cellular pathology began to be opposed by the doctrine of neurohumoral and hormonal regulatory systems of the body - this is how it appeared functional direction in medicine... However, it did not negate the role of the cell in pathology. At present, the cell, its constituent elements (ultrastructures) are approached as integral constituent parts of the whole organism, which are under the continuous influence and control of its neurohumoral and hormonal systems.
In the XX century, pathological anatomy began to develop rapidly, involving biochemistry and biophysics, immunology and genetics, molecular biology, electronics and computer science in solving their problems. In many countries, institutes of pathology have been established, fundamental guidelines and journals in pathological anatomy have emerged; the International, European and national scientific societies of pathologists were created.
The development of pathological anatomy in Russia
In our country, for the first time, autopsies began to be carried out in 1706, when medical hospital schools were organized by the decree of Peter I. However, the first organizers of the medical service in Russia N. Bidloo, I. Fischer, P. Kondoidi it was necessary to overcome the stubborn resistance of the clergy, who in every possible way prevented the autopsy.
It was only after the opening of the medical faculty at Moscow University in 1755 that autopsies began to be carried out quite regularly.
The first pathologists were the heads of the clinics F. F. Keresturi, E. O. Mukhin, L. I. Over and etc.
In 1849, at the initiative of the therapist professor I. V. Varvinsky the first in Russia department of pathological anatomy was opened at the Faculty of Medicine of Moscow University. The head of this department was his student A. I. Polunin(1820-1888), who is the founder of the Moscow school of pathologists and the pioneer of the clinical and anatomical direction in pathological anatomy.
Over the 140-year existence of the Department of Pathological Anatomy of Moscow University, and since 1930 - the 1st Moscow Medical Institute, the tradition is firmly maintained: the cathedral rod is passed from the hands of the teacher to the hands of the student. All seven heads of the department, being representatives of one school, from 1849 to the present, successively replaced each other: A. I. Polunin, I. F. Klein, M. N. Nikiforov, V. I. Kedrovsky, A. I. Abrikosov, A. I. Strukov, V. V. Serov.
A special place in the Moscow school of pathologists was occupied by M. N. Nikiforov(1858-1915), who headed the Department of Pathological Anatomy of Moscow University from 1897 to 1915. He not only performed valuable work on pathological anatomy, but created one of the best textbooks and prepared a large number of students who later headed the Department of Pathological Anatomy in various cities of Russia ...
The most talented student of M.N. Nikiforov was A. I. Abrikosov, who headed the Department of Pathological Anatomy of Moscow University from 1920 to 1952 and laid the scientific and organizational foundations of pathological anatomy in the USSR. He is rightfully considered the founder of Soviet pathological anatomy. A.I. Abrikosov has done outstanding research on the initial manifestations of pulmonary tuberculosis, tumors from myoblases, pathology of the oral cavity, pathology of the kidneys and many other issues.
He wrote a textbook for students, which went through 9 editions, created a multivolume manual on pathological anatomy for doctors, and trained a large number of students. A. I. Abrikosov was awarded the title of Hero of Socialist Labor and laureate of the State Prize.
The prominent representatives of the Moscow school of pathologists are M. A. Skvortsov (1876-1963), who created the pathological anatomy of childhood diseases, and I. V. Davydovsky(1887-1968), known for his work on general pathology, infectious pathology, gerontology and combat trauma, research on the philosophical foundations of biology and medicine. On his initiative, pathological anatomy began to be taught on the nosological principle. I.V. Davydovsky was awarded the title of Hero of Socialist Labor and laureate of the Lenin Prize. Among the staff of the Department of Pathological Anatomy of the I Moscow Medical Institute, students of A.I. Abrikosov, they made a great contribution to the development of pathological anatomy. S. S. Weil(1898-1979), who later worked in Leningrad, V. T. Talalaev (1886-1947), N. A. Kraevsky(1905-1985).
The Department of Pathological Anatomy in St. Petersburg was created in 1859 on the initiative of N.I.Pirogov. Here the glory of Russian pathological anatomy was created by M.M.Rudnev (1837-1878), G.V. Shor (1872-1948), N.N. Anichkov (1885-1964), M.F. Glazunov (1896-1967), F.F.Sysoev (1875-1930), V.G. Garshin (1877-1956), V.D. Tsinzerling (1891-1960). They trained a large number of students, many of whom headed departments at the Leningrad medical institutes: A. N. Chistovich(1905-1970) - at the S.M. Kirov Military Medical Academy, M. A. Zakharievskaya(1889-1977) - at the Leningrad Medical Institute named after I.P. Pavlov, P. V. Sipovsky(1906-1963) - at the State Institute for Advanced Training of Doctors. S. M. Kirov.
In the second half of the 19th and early 20th centuries, departments of pathological anatomy were opened at the medical institutes of Kazan, Kharkov, Kiev, Tomsk, Odessa, Saratov, Perm and other cities. After the October Revolution, departments of pathological anatomy were created in medical institutes of all union and autonomous republics, in many regional centers of the RSFSR. Schools of pathologists grew up here, whose representatives developed and continue to develop Soviet pathological anatomy: M. P. Mirolyubov(1870-1947) and I. V. Toroptsev In Tomsk, I.F. Pozharsky(1875-1919) and Sh. I. Krinitsky(1884-1961) in Rostov-on-Don, N. M. Lyubimov(1852-1906) and I. P. Vasiliev(1879-1949) in Kazan, P. P. Zabolotnov(1858-1935) and A.M. Antonov(1900-1983) in Saratov, P. A. Kucherenko(1882-1936) and M. X. Dahl in Kiev, N.F. Melnikov-Razvedenkov(1886-1937) and G.L.Derman(1890-1983) in Kharkov, etc.
During the years of Soviet power, pathologists launched scientific research in various branches of medicine, in particular infectious diseases. These works provided great assistance to Soviet health care in the elimination of a number of infections (smallpox, plague, typhus, etc.). Subsequently, pathologists have developed and continue to develop issues of early diagnosis of tumors, pay much attention to the study of cardiovascular and many other diseases, issues of geographic, regional pathology. Experimental pathology is developing successfully.
A pathological service has been created in the country. Each hospital has a pathology department headed by the head - a pathologist. In large cities, central pathological laboratories have been created to organize the work of pathologists. All deceased in hospitals or clinics of medical institutes are subject to postmortem examination. It helps to establish the correctness of the clinical diagnosis, to identify defects in the examination and treatment of the patient. Clinical and anatomical conferences are organized to discuss medical errors detected during autopsy and to develop measures to eliminate deficiencies in medical work. Materials of pathological conferences are generalized and contribute to the improvement of the qualifications of doctors, both clinicians and pathologists.
Lecture 1. Pathological anatomy
1. Tasks of pathological anatomy
4. Death and postmortem changes, causes of death, thanatogenesis, clinical and biological death
5. Cadaveric changes, their differences from intravital pathological processes and significance for the diagnosis of the disease
1. Tasks of pathological anatomy
Pathological anatomy- the science of the origin and development of morphological changes in a sick organism. It originated in an era when the study of morbidly altered organs was carried out with the naked eye, that is, by the same method used by anatomy, which studies the structure of a healthy organism.
Pathological anatomy is one of the most important disciplines in the system of veterinary education, in the scientific and practical activities of a doctor. She studies the structural, that is, the material basis of the disease. It relies on data from general biology, biochemistry, anatomy, histology, physiology and other sciences, which study the general laws of life, metabolism, structure and functional functions of a healthy human and animal organism in its interaction with the external environment.
Without knowing what morphological changes in the animal's body are caused by the disease, it is impossible to have a correct understanding of its essence and mechanism of development, diagnosis and treatment.
The study of the structural foundations of the disease is carried out in close connection with its clinical manifestations. Clinical and anatomical direction is a distinctive feature of Russian pathological anatomy.
The study of the structural foundations of the disease is carried out at different levels:
· The organismic level allows to reveal the disease of the whole organism in its manifestations, in the interconnection of all its organs and systems. From this level, the study of a sick animal in clinics, a corpse - in a section hall or a cattle cemetery begins;
· The systemic level studies any system of organs and tissues (digestive system, etc.);
· The organ level allows you to determine the changes in organs and tissues visible with the naked eye or under a microscope;
· Tissue and cellular levels - these are the levels of studying altered tissues, cells and intercellular substance using a microscope;
· The subcellular level makes it possible to observe, with the help of an electron microscope, changes in the ultrastructure of cells and intercellular substance, which in most cases were the first morphological manifestations of the disease;
· The molecular level of the study of the disease is possible using complex research methods involving electron microscopy, cytochemistry, radioautography, immunohistochemistry.
Recognition of morphological changes at the organ and tissue levels is very difficult at the onset of the disease, when these changes are insignificant. This is due to the fact that the disease began with a change in subcellular structures.
These levels of research make it possible to consider structural and functional disorders in their indissoluble dialectical unity.
2. Objects of research and methods of pathological anatomy
Pathological anatomy deals with the study of structural disorders that have arisen at the very initial stages of the disease, in the course of its development, up to the final and irreversible conditions or recovery. This is the morphogenesis of the disease.
Pathological anatomy studies deviations from the usual course of the disease, complications and outcomes of the disease, necessarily reveals the causes, etiology, pathogenesis.
The study of the etiology, pathogenesis, clinical picture, morphology of the disease makes it possible to apply scientifically based measures for the treatment and prevention of the disease.
The results of observations in the clinic, studies of pathophysiology and pathological anatomy have shown that a healthy animal organism has the ability to maintain a constant composition of the internal environment, a stable balance in response to external factors - homeostasis.
With a disease, homeostasis is disturbed, vital activity proceeds differently than in a healthy organism, which is manifested by structural and functional disorders characteristic of each disease. Disease is the life of an organism in the changed conditions of both the external and internal environment.
Pathological anatomy also studies changes in the body. Under the influence of drugs, they can be positive and negative, causing side effects. This is the pathology of therapy.
So, pathological anatomy covers a wide range of issues. She sets herself the task of giving a clear idea of the material essence of the disease.
Pathological anatomy seeks to use new, more subtle structural levels and the most complete functional assessment of the altered structure at equal levels of its organization.
Pathological anatomy gains material about structural abnormalities in disease through autopsy, surgery, biopsy, and experimentation. In addition, in veterinary practice with a diagnostic or scientific purpose, the forced slaughter of animals is carried out at different periods of the disease, which makes it possible to study the development of pathological processes and diseases at different stages. A great opportunity for pathological examination of numerous carcasses and organs is presented at meat processing plants when animals are slaughtered.
In clinical and pathomorphological practice, biopsies are of certain importance, that is, the intravital collection of pieces of tissues and organs, carried out for scientific and diagnostic purposes.
Particularly important for elucidating the pathogenesis and morphogenesis of diseases is their reproduction in experiment. The experimental method makes it possible to create models of the disease for their accurate and detailed study, as well as for testing the effectiveness of therapeutic and prophylactic drugs.
The possibilities of pathological anatomy have expanded significantly with the use of numerous histological, histochemical, autoradiographic, luminescent methods, etc.
Proceeding from the tasks, pathological anatomy is placed in a special position: on the one hand, it is the theory of veterinary medicine, which, revealing the material substrate of the disease, serves clinical practice; on the other hand, it is a clinical morphology for establishing a diagnosis, serving the theory of veterinary medicine.
3. A brief history of the development of pathological anatomy
The development of pathological anatomy as a science is inextricably linked with the autopsy of human and animal corpses. According to literary sources in the II century AD. NS. Roman physician Galen opened the corpses of animals, studying their anatomy, physiology, and described some of the pathological and anatomical changes. In the Middle Ages, due to religious beliefs, the autopsy of human bodies was prohibited, which somewhat halted the development of pathological anatomy as a science.
In the XVI century. in a number of Western European countries, doctors were again granted the right to perform autopsies on human corpses. This circumstance contributed to the further improvement of knowledge in the field of anatomy and the accumulation of pathological and anatomical materials in various diseases.
In the middle of the 18th century. A book by the Italian physician Morgagni "On the localization and causes of diseases identified by an anatomist" was published, where the scattered pathological and anatomical data of their predecessors were systematized and their own experience was summarized. The book describes changes in organs in various diseases, which facilitated their diagnosis and promoted the role of pathological and anatomical research in establishing the diagnosis.
In the first half of the 19th century. in pathology, the humoral trend prevailed, the supporters of which saw the essence of the disease in the change in the blood and juices of the body. It was believed that at first there is a qualitative violation of blood and juices, followed by a deviation of "disease-causing matter" in the organs. This teaching was based on fantastic ideas.
The development of optical technology, normal anatomy and histology created the prerequisites for the emergence and development of cell theory (Virkhov R., 1958). The pathological changes observed in a particular disease, according to Virchow, are a simple sum of the disease state of the cells themselves. This is the metaphysical nature of the teachings of R. Virchow, since he was alien to the idea of the integrity of the organism and its relationship with the environment. However, Virchow's doctrine served as an incentive for a deep scientific study of diseases through pathological, anatomical, histological, clinical and experimental research.
In the second half of the XIX and early XX centuries. in Germany worked great pathologists Kip, Yost, authors of fundamental guidelines on pathological anatomical anatomy. German pathologists conducted extensive research on equine infectious anemia, tuberculosis, foot and mouth disease, swine fever, etc.
The beginning of the development of domestic veterinary pathological anatomy dates back to the middle of the 19th century. The first veterinary pathologists were professors of the veterinary department of the St. Petersburg Medical-Surgical Academy I. I. Ravich and A. A. Raevsky.
Since the end of the 19th century, Russian pathological anatomy has received its further development within the walls of the Kazan Veterinary Institute, where since 1899 Professor K.G.Bol was the head of the department. He penned a large number of works on general and specific pathological anatomy.
Research carried out by domestic scientists is of great scientific and practical importance. A number of important studies have been carried out in the field of studying theoretical and practical issues of the pathology of agricultural and game animals. These works made a valuable contribution to the development of veterinary science and animal husbandry.
4. Death and posthumous changes
Death is the irreversible cessation of the vital functions of the body. This is the inevitable end of life that occurs as a result of illness or violence.
The dying process is called agony. Depending on the cause, the agony can be very brief or last up to several hours.
Distinguish clinical and biological death... Conditionally, the moment of clinical death is considered to be the cessation of cardiac activity. But after that, other organs and tissues with different durations still retain vital activity: intestinal peristalsis, secretion of glands continue, and muscle excitability remains. After the termination of all vital functions of the organism, biological death occurs. Posthumous changes occur. Studying these changes is important for understanding the mechanism of death in various diseases.
For practical activity, the differences in morphological changes that have arisen in vivo and posthumous are of great importance. This contributes to the establishment of the correct diagnosis, and is also important for the forensic veterinary examination.
5. Cadaveric changes
· Cooling of a corpse. Depending on the conditions, at the expiration of various periods, the temperature of the corpse becomes equal to the temperature of the external environment. At 18–20 ° C, the body is cooled by one degree every hour.
· Rigor mortis. After 2–4 hours (sometimes earlier) after clinical death, smooth and striated muscles contract somewhat and become dense. The process begins with the jaw muscles, then spreads to the neck, forelimbs, chest, belly and hind quarters. The greatest degree of rigor mortis is observed after 24 hours and persists for 1–2 days. Rigor then disappears in the same sequence as it arises. Rigor of the heart muscle occurs 1-2 hours after death.
The mechanism of rigor mortis is still not well understood. But the significance of two factors is well established. With the postmortem breakdown of glycogen, a large amount of lactic acid is formed, which alters the chemistry of muscle fibers and contributes to rigidity. The amount of adenosine triphosphoric acid decreases, and this leads to the loss of the elastic properties of the muscles.
· Cadaveric spots are caused by changes in the state of the blood and its redistribution after death. As a result of posthumous contraction of the arteries, a significant amount of blood passes into the veins, accumulates in the cavities of the right ventricle and atria. Postmortem blood clotting occurs, but sometimes it remains liquid (depending on the cause of death). At death from asphyxia, the blood does not clot. There are two stages in the development of cadaveric spots.
The first stage is the formation of cadaveric hypostases, which occur 3-5 hours after death. Blood by gravity moves to the lower parts of the body and seeps through the vessels and capillaries. Spots are formed that are visible in the subcutaneous tissue after removing the skin, in the internal organs - upon opening.
The second stage is hypostatic imbibition (soaking).
In this case, interstitial fluid and lymph penetrate into the vessels, blood thinning occurs and hemolysis increases. The diluted blood seeps out of the vessels again, first to the underside of the corpse, and then everywhere. The spots have indistinct outlines, and when cut, it is not blood that flows out, but a sacral tissue fluid (unlike hemorrhages).
· Corpse decomposition and putrefaction. In the dead organs and tissues, autolytic processes develop, called decomposition and due to the action of the deceased organism's own enzymes. Disintegration (or melting) of tissues occurs. The earliest and most intensively these processes develop in organs rich in proteolytic enzymes (stomach, pancreas, liver).
The decay is then joined by the rotting of the corpse, caused by the action of microorganisms, which are constantly present in the body during life, especially in the intestines.
Rotting occurs first of all in the digestive organs, but then spreads to the entire body. During the putrefactive process, various gases are formed, mainly hydrogen sulfide, a very unpleasant odor arises. Hydrogen sulfide, when interacting with hemoglobin, forms iron sulfide. A dirty greenish color of cadaveric spots appears. Soft tissues swell, soften and turn into a gray-green mass, often riddled with gas bubbles (cadaveric emphysema).
Putrefactive processes develop faster at higher temperatures and higher environmental humidity.
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1.1. I PERIOD -
"ANATOMIC" OR "MACROSCOPIC"
During the first period of the history of pathological anatomy - "anatomical" or "macroscopic", pathological changes in organs were studied only visually - changes in their size, consistency, color, etc. were recorded. The object of the study was the corpses of deceased people and animals. Important data were also obtained during examination, palpation and dissection of tissues and organs during the treatment of various injuries and diseases.
For a long time, morphological knowledge did not stand out as an independent medical discipline. The first period of development of pathological anatomy as science actually began after the publication in 1761 of the 5-volume work of J. Morgagni "On the location and causes of diseases identified by the anatomist", and ended in 1842-1846. with the advent of the multivolume "Guide to private pathological anatomy" by K. Rokitansky.
The first period of development of pathological anatomy is the longest, heterogeneous and contradictory. It is still extremely insufficiently studied, although there is a lot of fragmentary information about a good knowledge of normal and pathological anatomy by priests and healers of various ancient civilizations (Ancient Egypt, Asia Minor, India, China, Ancient Greece and Rome, etc.), as well as medical scientists of the Middle Ages in European and other countries.
Such a term as "pathological anatomy" did not exist until the middle of the 18th century, morphological knowledge about the substrate of diseases was an integral part of medicine (the medical profession) as a whole or, in the 13th - 18th centuries in Europe, a part of practical (medical) anatomy. Many morphological knowledge was repeatedly lost and re-accumulated with the change of different civilizations.
V Ancient egypt people of the medical profession (priests) had a fairly complete understanding of the anatomy and pathological changes in organs in various diseases (tumors, infections, etc.), primarily due to the practice of embalming the bodies of the dead. However, for thousands of years, ancient Egyptian medicine was limited by strict religious frameworks, autopsies of the dead for medical purposes were prohibited.
V ancient chinese medicine there are known works dated 2-3 millennia BC. (for example, the composition of Nuen King in 2637 BC), based on the results of autopsies, where the circulatory system is described, for the first time the role of the heart is shown (the discovery is usually attributed to Aristotle), the morphology of various organs. Then for a long time, until the 18th century, autopsies were not allowed in China. Since the works of Chinese scientists are the oldest surviving written sources on the production of autopsies for medical purposes, it is believed that the history of autopsies dates back to them and has about 4500 years.
V India autopsies were not prohibited, but in the ancient Indian work on medicine "Ayur Veda" there are few morphological data, although for the first time four main signs of inflammation (redness, swelling, fever and pain) are described, repeated in Europe at the beginning of our era in the writings of Celsus and Galen (with the addition of the fifth sign - dysfunction).
V ancient Greece and Rome professional physicians appeared from the 12th century BC, in the Roman Empire, medicine continued to develop and was accumulated, later partially lost, extensive material on normal and pathological human anatomy (known thanks to the works of Aristotle, Hippocrates and his followers, later - Celsus and Galen ), although the terms "anatomy" or "pathology" have not yet been used. The first anatomist is considered a student of Pythagoras, the physician Alcmenes of Croton (500 BC), who is credited with opening the optic nerve. Aristotle (born in 384 BC) was the first in ancient medicine to connect the manifestations of diseases with damage to specific organs, and discovered the role of the heart.
With great benefit for the development of medicine, but within a short historical period of time, autopsies were carried out by scientists (Geraphilus, Erazistratus, etc.) of the Alexandrian school (300 AD). Gained worldwide fame and were relevant for many generations of doctors over the next 1000 years, the works of the physician and anatomist Claudia Galena (K. Halen)(130 - 200 AD), who worked in the largest "scientific center" in those years in the Mediterranean - in Alexandria (Egypt) and wrote the first known textbook on human anatomy based on research on corpses, mainly animals. With the help of experiments on animals, Galen was the first to establish the role of the central nervous system, the connection between mental activity and the brain. He also described the types of inflammation, tumors, the morphology of many diseases, summarizing the knowledge of doctors in Greece and Rome.
After the collapse of the Roman Empire in the 5th century, the ancient medical knowledge of the Mediterranean countries was concentrated among the Arab physicians, who not only restored the Alexandrian school, but also significantly enriched it. However, due to the dogmas of Islam, which strictly forbade the autopsy of the dead and images of the human body, normal and pathological anatomy did not develop.
The medical knowledge of Arab scientists was transferred to doctors of the countries of southern Europe - Italy, Spain, Portugal and France. It is generally accepted that this, in the 11th - 12th centuries, ends the first, longest and most ancient stage of the first period in the history of pathological anatomy.
Until the beginning of the 13th century, autopsies were prohibited in Europe for religious reasons. The origins of this prohibition lie in various religions of Ancient Egypt and Asia Minor (only autopsies were allowed for the purpose of embalming corpses). Even the bull of Pope Boniface VIII of 1300, which forbade the dismemberment of corpses for long-distance transportation and burial, was widely misunderstood as banning autopsy and anatomical research. For some time, the autopsies were carried out in secret, and the scientists who produced them were persecuted. Only 250 years later, an autopsy was recommended by the bull of Pope Pius IV to determine the cause of death.
In 1242, King Frederick II of Sicily and Italy granted the Medical School in Bologna (Italy) the right to receive the corpses of two executed criminals per year for autopsies. In England, since 1300, a charter from King Henry VIII of the Barber and Surgeon Association also granted the right to autopsy four executed criminals a year. Autopsies of the executed were allowed to be carried out in Vienna from 1403, in Prague - from 1600.
Thus, in the Middle Ages in Europe, autopsies were a single and exceptional event. Their spread was also hampered by the lack of inpatient medical institutions (although the first hospitals were organized in the ancient world). Professor at the University of Padua Bertelemi Montagnano (B. Montagnana)(born in 1460) became widely known for having performed 14 autopsies, which was extremely high for that time.
As you can see, the first period in the history of pathological anatomy (anatomical, or macroscopic) unites a variety of eras, but pathological anatomy, even as an integral part of anatomy and surgery, began to develop intensively only in the XV-XVII centuries, thanks to the emergence of scientific biology, anatomy and physiology.
In the XIV-XVI centuries, anatomical studies of corpses, carried out by many European medical scientists and encyclopedists of the Renaissance, spread, a modern scientific approach to human anatomy and pathology began to form.
For example, Leonardo da Vinci(1452-1519) performed autopsies on more than 30 corpses to study human anatomy. Not only normal, but also pathological anatomy was developed Vesalius(1514-1564), the largest anatomist, his students Eustachius, Fallopius and Arantius.
Paracelsus, Professor at the University of Basel, surgeons A. Paré, V. Fabri, anatomist Harvey(who opened a large circle of blood circulation) and others actively promoted pathological studies of corpses. The inventors of the syringe carried out autopsies, filling the vessels with different materials (paints, wax) Jacobus Berengarus(1470-1550) and Reginiere de Graaf (1641-1673).
J. Fernel(1497-1558) in his work "Pathology" - the first manual with such a title, summarized the materials of many autopsies, first described appendicitis (without using this term), syphilitic aortic aneurysm, etc.
In the 17th century Carl Linnaeus, Marcello Malpighi(opened the capillaries), Mark Severin(describing benign and malignant tumors), Sylvius(described pulmonary tuberculosis), Jacob Wepfer(who first explained the connection between apoplexy and cerebral hemorrhage), Glisson and Willis (Willis) not only performed postmortem autopsies, but also pointed out their exceptional role in elucidating the causes of death of specific patients and the development of medicine in general. In the 17th century, museums of pathological preparations began to open in Europe.
T.Bone (Bonetus) in 1676 he was one of the first to systematize the results of about 3000 autopsies, the descriptions of which he collected in the literature since the time of Hippocrates, i.e. for 2000 years, and showed the existence of a connection between morphological changes in organs and clinical manifestations of diseases.
The Dutch physician (anatomist, surgeon and forensic physician) made a great contribution to the development of scientific normal and pathological anatomy Frederic Ruysch(F. Ruysch) (1638-1731). F. Ruysch in the guild of surgeons in Amsterdam performed forensic and pathological autopsies, founded an anatomical museum, apparently one of the first in the world. It was he who presented his anatomical museum to Peter I, who, during his stay in Holland in 1689, even assisted Ruysch in autopsies.
As a result, in 1707, by decree of Peter I, autopsies were organized in the first Russian hospital (now the Main Military Hospital named after N.N.Burdenko in Moscow), and in 1717 part of the anatomical collection of F. Ruysch was acquired for Russia and formed the basis of the Kunstkamera in St. Petersburg.
By the end of the 17th - beginning of the 18th centuries, extensive materials of the results of postmortem autopsy had been accumulated, but it was not possible to generalize them for a long time.
The first period in the development of pathological anatomy as a science actually began after the publication in 1761 of a 5-volume work by a professor at the universities of Bologna and Padua, a student of the anatomist Valsalva - Giovanni Morgagni(1682-1771) "On the location and causes of diseases identified by the anatomist", and ended in 1842-1846. with the advent of the multivolume "Guide to Private Pathological Anatomy" by K. Rokitansky. J. Morgagni for the first time conducted clinical and anatomical comparisons based on the results of 700 pathological autopsies, presented pathological descriptions of many diseases, indicated the correct place of pathological anatomy among clinical disciplines.
Marie Bisha (M.Bishot)(1771-1802) introduced pathological anatomy into clinical practice, he proposed to study damage at the tissue level, created a classification of tissue types (connective, muscle, adipose, bone, etc.). M. Bish's student - F. Brousset created a doctrine that rejects the existence of diseases that do not have a material substrate.
J. Cruvellier(1771-1873), a student of Dupuytren, the first professor of pathological anatomy at the University of Paris, in 1829-1835. created and published the world's first color atlas on pathological anatomy.
Karl Rokitansky(K. Rokitansky) (1804-1878), a Czech scientist, professor of pathological anatomy at the University of Vienna, for the first time systematized and outlined the private pathological anatomy according to the organ principle ("Guide to private pathological anatomy", 1842-1846), presented changes in the organs in accordance with the various stages of development of all then known major diseases. K. Rokitansky was the first to use statistical methods in pathological anatomy. R. Virkhov called K. Rokitansky “Linnaeus of pathological anatomy”.
K. Rokitansky was the first pathologist who was not directly involved in clinical activities, actively promoted the teaching of pathological anatomy and contributed to the opening of departments of pathological anatomy at European universities. However, although only single microscopic (histological) descriptions were presented in his manual, their role was still small.
By this time, however, it became clear that in many severe organ dysfunctions, it was not possible to reveal their macroscopic (anatomical) changes. It was this fact that subsequently formed the basis for the erroneous identification of "functional" diseases, as if they did not have their own structural expression. In addition, K. Rokitansky explained the origin and essence of pathological processes from the point of view of humoral ideas - the doctrine of "krazy" - dyscrasias (K. Rokitansky - the founder "Humoral" pathology However, later he accepted the ideas of cellular pathology of R. Virchow).
K. Rokitansky founded the Department of Pathological Anatomy at the University of Vienna and created the world's largest pathological museum. His name is associated with the final separation of pathological anatomy into an independent scientific discipline and medical specialty.
1.2. PERIOD II -
"MICROSCOPIC"
The second period in the history of pathological anatomy ("microscopic") associated with the name of R. Virkhov and with the publication in 1858 of his manual "Cellular pathology".
This period was made possible by the invention of the microscope and the approval in 1838-1839. cell theory of the structure of organisms by Schleiden (1804-1881) and Schwann (1810-1882). In addition to Schleiden and Schwann, a large role in the formation of cell theory belongs to Hooke, Malpighi, Purkinje, P.F. Goryaninov, Müller.
Rudolf Virchov(1821-1902), a German scientist, professor at the University of Berlin, refuted the theory of dyscrasia - humoral pathology by K. Rokitansky and created the theory “ cellular "or « cellular "pathology, which was a turning point in the development of pathological anatomy and medicine in general. The main idea of R. Virkhov's work "Cellular pathology" (1858) was that all pathology is a pathology of cells. He was the first to describe and name such pathological processes as embolism, leukemia, amyloidosis, etc.
R. Virkhov is the founder of the Department and Institute of Pathology in Berlin, a journal on pathological anatomy ("Virchow Archive"), the founder of the world-famous museum of macro-preparations (more than 25,000 macro-preparations). Cellular pathology, which at one time was the highest scientific achievement of medicine, had, however, serious drawbacks, for example, it considered the cells of the body as independent independent cells. This theory was subsequently significantly supplemented by ideas about humoral and nervous regulatory processes, intercellular interactions, etc.
Thus, the classic work of R. Virkhov "Cellular pathology" with a detailed microscopic description of morphological changes in organs and tissues in various diseases marked the beginning of the second period of development of pathological anatomy - "microscopic".
Later, the development of histological technology, histology, histochemistry made it possible to identify the structural bases of most diseases and significantly reduce the range of so-called "Functional" diseases.
However, by the middle of the twentieth century, the second crisis of the clinical and anatomical direction arose again, tk. it became necessary to investigate not the cell, but the subcellular and molecular structural bases of diseases.
1.3. PERIOD III -
"ULTRAMICROSCOPIC"
The invention of the electron microscope made it possible in the 50s of the twentieth century to move on to the study of pathological processes at the ultrastructural level and laid the foundation for the third period of development of pathological anatomy - "ultramicroscopic".
In the future, immunomorphological, radiographic and others were added to the electron microscopic method of research, which made it possible to study the subtlest intracellular changes, brought pathological anatomy closer to molecular pathology, pathological physiology and biochemistry, genetics and immunology, put an end to the division of diseases into "structural" and "functional" ...
Thus, in the course of its development, pathological anatomy has gone the way of studying different levels of organization of living organisms - from organismic and organ, to tissue and cellular, and then - intracellular and molecular. Each subsequent period in the development of pathological anatomy did not deny, but added new data on pathological processes and diseases at a more subtle level of organization of living things, creating a single holistic picture of structural and functional changes. At the same time, it turned out that the study of pathological processes at only one level, be it molecular and subcellular, or organ and tissue, leads to gross errors. Modern pathoanatomical studies seem to repeat the "phylogenesis" of pathological anatomy - pathological processes are studied from the macroscopic to ultramicroscopic (molecular) level. The object of research in pathological anatomy, already from the second period of its development, was not only the corpses of the dead, but also the material obtained in vivo (operational and diagnostic biopsies), the results of experimental studies.
1.4. IV PERIOD -
"LIFE PATHOLOGICAL ANATOMY"
The works of the French morphologists M. Bichat, J. Corvisard and J. Cruvellier, who created the world's first color atlas on pathological anatomy, were of great importance for the development of pathological anatomy. R. Beil was the first author of a complete textbook on private pathological anatomy, translated into Russian in 1826 by the doctor A.I.Kostomarov. K. Rokitansky was the first to systematize the pathological processes of the body systems in various diseases, and also became the author of the first manual on pathological anatomy.
In Russia, for the first time, autopsies began to be performed in 1706, when, by order of Peter I, medical hospital schools were organized. But the clergy obstructed the autopsy. It was only after the opening of the medical faculty at Moscow University in 1755 that autopsies began to be carried out regularly.
The first in Russia department of pathological anatomy and pathological physiology was organized in 1849 at Moscow University by the famous therapist A.I. Polunin. He was the first to understand the need to compare the manifestations of the disease that existed during the patient's life with the changes that were revealed during the autopsy. A.I. Polunin is the founder of the clinical and anatomical direction, which has become a characteristic feature of domestic medicine. AI Polunin's ideas were continued and developed by his numerous students and followers. Among them is the founder of the Moscow School of Pathologists, the author of the first Russian textbook on pathological anatomy, prof. M.N. Nikiforov. MN Nikiforov's students were academicians A. I. Abrikosov and I. V. Davydovsky. Developing the ideas laid down by A.I. Polunin and M.N. Nikiforov, A.I. Abrikosov created the principles of domestic pathological anatomy and made a great contribution to the development of many problems of general and particular pathology. IV Davydovsky proved the patterns of development of pathological processes and diseases; he is responsible for major research in the field of general pathology, wartime pathology. MN Nikiforov's student was Professor MA Skvortsov - the recognized founder of pediatric pathological anatomy.
The successor to the ideas of the Moscow school of pathologists was A. I. Abrikosov's student, academician A. I. Strukov. His name is associated with the development of the pathomorphology of tuberculosis, rheumatic diseases, pathology of microcirculation, inflammation, as well as the introduction of new research methods into pathological anatomy - histochemistry, histofermentochemistry, electron microscopy, which gave it a functional orientation. The modern stage in the development of pathological anatomy is characterized by the emergence of molecular pathology, which studies diseases at the molecular level, providing intercellular relations. This direction in our country is headed by Academician M.A.Paltsev.
Pathological physiology developed in parallel with pathological anatomy. In 1849, the same professor A.I. Polunin became the founder of the department of pathological physiology at Moscow University. During this period, animal experiments have already become firmly established in the arsenal of scientific research methods. The basis for the development of pathological physiology was the research of physiologists I.M.Sechenov, I.P. Pavlov, N.E. Vvedensky, therapist S.P. Botkin.
In the creation of the departments of general and experimental pathology (pathological physiology) in Russia, great merit belongs to the outstanding physiologist, a student of I.M.Sechenov - prof. V.V. Pashutin. His scientific research focused on the mechanisms of metabolic disorders, starvation and endocrine system pathology. A major contribution to the development of general pathology was made by the domestic pathophysiologists professors A.B. Fokht, A.A. Bogomolets, N.N. Anichkov, S.S.Khalatov, A.D. Speransky. N.N. Sirotinin. Who developed various aspects of the problems of reactivity, aging, pathology of the endocrine system. N. N. Anichkov and S. S. Khalatov created the first experimental model of atherosclerosis and did much to understand the mechanisms of its development.
A great contribution to the development of pathology was made by major foreign physiologists and morphologists - K. Bernard. W. Cannon. K. Rokitansky, R. Virkhov, G. Selye. Thus, the famous physiologist of the 19th century K. Bernard is the founder of the experimental physiological direction in pathology and the doctrine of the constancy of the internal environment of the body - homeostasis. The largest German pathologist R. Virchow is the founder of the doctrine of cellular pathology. The cellular theory of pathology has become a powerful stimulus for the study and systematization of cellular and later subcellular mechanisms of disease development. The studies of G. Selye, who showed the important role of the neuroendocrine system in the formation of adaptive reactions and disorders of vital activity, were widely known and spread. He is the founder of the doctrine of stress.
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