TERRITORIAL MEDICINE — the form of medical and sanitary providing mainly country people which arose in Russia after cancellation of serfdom (since 1864). 3. for the first time in the history of medicine and health care developed m and implemented a new form of the organization of medical aid — a territorial uchastkovost, edges further on essentially other social and economic basis it was developed by the Soviet health care.
Emergence 3. by m it is directly connected with territorial reform — introduction in 1864 of so-called territorial economic self-government in 34 (from 89) provinces of the Russian Empire, hl. obr. in central; in 1911 the zemstvo was entered still in 6 zap. provinces. Characterizing territorial reform, V. I. Lenin wrote that it «... was one of those concessions which the wave of public excitement and a revolutionary impact» (V. I. Lenin fought off the autocratic government, Half-N of SOBR. soch., 5th prod., t. 5, page 33). According to V. I. Lenin, «... the zemstvo was from the very beginning condemned on being the fifth wheel in the cart of the Russian public administration, the wheel allowed by bureaucracy only so far as its absolute power was not broken» (V. I. Lenin, Half-N of SOBR. soch., 5th prod., t. 5, page 35). «A zemstvo — a piece of the constitution. Let so. But it is such piece by means of which Russian "society" of an otmanivala from the constitution. It is such, rather very unimportant position which the autocracy yielded to the growing democratism to reserve the main positions to divide and separate those who demanded transformations political» (V. of PI. Lenin, Half-N of SOBR. soch., 5th prod., t. 5, page 65). Created in social and economic conditions of Russia of the second half 19 — the beginnings of 20 century 3. m reflected the contradictions inherent in this period: a combination of the developing capitalist farm patterns to even quite hardy and considerable remains of a feudal system, domination of the nobility in government and the aspiration of the bourgeoisie to participate in public administration; mass actions of the peasantry and especially emergence and development of labor movement were of great importance. The dominating role in zemstvoes belonged to landowners-noblemen. Participation of peasants was insignificant, their single representatives were not elected, and were appointed the authorities. The noble zemstvo was directly interested in preservation of tax solvency of country economy. The landowners aiming at increase in grain export and the manufacturers who were looking for cheap labor had to take care, naturally, at least about nek-rum a minimum medical - a dignity. service of the peasantry providing continuous inflow of healthy labor. The peasantry representing the fertile field for distribution of epidemics interfering development of trade with the West, especially grain export needed a certain organization of medical aid of public character especially as living conditions of the peasantry least of all could attract to the village of private medical practitioners whom was in general very little. The nobility received the known benefits from opening at the expense of a zemstvo near the estates medical - a dignity. the institutions guaranteeing them in a nek-swarm to a measure against danger of distribution of epidemics.
Development of territorial medical network. Steps of a zemstvo in the field of the organization of medical aid were very indecisive; only those events which were caused extreme neobkhodimostyo and did not contradict interests of ruling classes were held.
According to «The provision on territorial institutions» (1864) care in limits was assigned to a zemstvo «, the law of certain and it is preferential in the economic relation, about national health. However «care about national health» was referred to number of optional duties of a zemstvo. The law obliged zemstvoes to support only the institutions of the former orders of public contempt transferred to them (519 BCs, 33 «a shelter for mad», 113 «almshouses and houses for incurable» and 23 «orphan houses») and to take measures to the organization of smallpox vaccination. The exact regulation of obligations of zemstvoes for rendering medical assistance to country people did not exist. Many territorial figures objected to the invitation to constant service of doctors and found it possible to attract for reasons of economy to these purposes of priests, teachers or paramedics, the Crimea the right of independent treatment of patients was granted («the doctor is the lordly doctor, the paramedic — rustic»). But ongoing heavy epidemics of cholera, smallpox, typhus in the country, etc. forced even the most reactionary part of zemstvoes to increase allocations for medical needs, to call doctors, to create at first temporary first-aid posts, and then to turn them into constants.
Development 3. the m is characterized first of all by increase in number of doctors in the village; their especially rapid growth falls on the first years. In the beginning in a zemstvo the doctors who passed from government service (district, city) and from the former orders of public contempt prevailed. However soon to territorial provinces arrived many young doctors who left the circle of small officials, the lowest clergy, narrow-mindedness (commoners). Territorial institutions became the place of public work of democratically spirited Russian intelligentsia — statisticians, agronomists, doctors. Doctors and statistics did not belong neither to administration, nor to representatives of estates in a zemstvo. It was the so-called third element — the people acting from interests of medical business «... from interests of statistics and not reckoning with interests of ruling estates» (W. I. Leni of N, Poln, SOBR. soch., 5th prod., t. 5, page 329). Coming to zemstvoes from the capital or other university centers with the aspiration to serve the people, and sometimes and to conduct revolutionary promotion, they did not allow to concern themselves as to simple mercenaries, considered themselves the citizens executing certain public functions. It brought «... to the conflicts of upravsky bigwigs with doctors who collectively resigned, with technicians etc.» (V. I. of JI e of N and N, Half-N of SOBR. soch., 5th prod., t. 5, page 330). During an initial stage of a zemstvo there was that type of the territorial doctor — the carrier of high moral ethical standards and public principles which exerted impact on formation of the best traditions of public medicine at a lineage of domestic doctors. These traditions found the fullest embodiment and further development in the Soviet medicine.
In the first years in 3. m the so-called traveling system of medical service practiced: the doctor living in the city or in the county at out-patient clinic had to go round infirmaries of the county which were at the head of the paramedic, having short-term medical preparation, for control of activity of paramedics and rendering medical assistance to the population from time to time (once a month or is more rare). Existence of such system of a zemstvo was justified with reasons of economy and need of so-called leveling service of all country population as it paid so-called leveling territorial collecting. Most of territorial doctors was negative to traveling system («the doctor always in driving, and patients do not know where to find the doctor»). Initial stage 3. the m is characterized by persistent fight of territorial doctors against owners of zemstvoes not only for recognition of need of the doctor for the village, but also for introduction of stationary system instead of traveling (stationary was understood in this case as not existence of bed institutions, but constant stay of the doctor in a certain place). So, medical congresses in 70th and 80th 19 century demanded cancellation of traveling system. Gradually traveling system, through the intermediate form — mixed was replaced by stationary. At the mixed form there were already constant medical points, doctors left them only in case of emergency: at poisonings, difficult childbirth, severe injuries, epidemics, etc. In the early eighties 19 century more advanced economically zemstvoes started construction of rural clinics, began to call in them doctors; these years, according to incomplete data, the traveling system existed in 134 counties, in 206 was mixed and only in 19 counties the stationary system appeared. In 20 years, by 1900, the mixed system was presented in 219 counties, traveling remained only into two, and 138 counties passed to stationary system. Emergence in zemstvoes of two and more doctors on the county created a possibility of division of the territory it on sites according to the number of doctors and constant (stationary) placement them in certain points of the county (it is not obligatory with existence of hospital). Thereby for the first time the system of medical service which afterwards developed into uchastkovoterritorialny arose. Emergence of the medical site in the village — for the first time in the history of health care — one of serious merits 3. m.
Increase in number of doctors and medical institutions in the village raised a question of their correct placement. One of prominent territorial doctors A. P. Voskresensky accurately stated the structural principles of the medical site: «... shall aim not at centralization, not at the structure of big hospitals in one-two places of the county..., and to decentralization, to possible approach of doctors to the population, to that the normal network of medical sites was founded: i.e. their such number, at Krom patients — at not distant accommodation from them of the doctor, would find possible to overcome this distance, to go to the doctor for the help...». The medical site had to include a local clinic which entered: 1) a hospital (as a rule, on 5 — 10 beds) with maternity and syphilitic departments; 2) infectious barrack; 3) out-patient clinic for reception of the coming patients. Also the room for a drugstore, the apartment for the doctor, the house for personnel was provided. However in many zemstvoes there were not all these structural divisions. Territorial medical figures believed that the medical site in the village shall have radius within 10 versts, the area of 314 sq. versts with the population on site 6 — 6,6 thousand persons.
Negotiability of country people to local clinics was in direct dependence on distance: at distance (radius) to a local clinic in 5 — 6 versts negotiability was close to 100% (from all diseased), at distance in 7 — 12 versts — fell to 50%, and at bigger distance, considering a state of disrepair of roads, hardly reached 20% a year.
Along with the territorial medical site in 3. m were created territorial district and provincial-tsy, the resulted reorganization of orders of public contempt in the district and provincial centers. These would be reconstructed, the bed fund is expanded. In provincial a prozektura, operating rooms of new type would be created, the medical staff and other medical personnel extended. Some innovations were carried out also in district-tsakh.
Thus, there was a structure of the organization of medical service of country people including three links of medical assistance: the territorial medical site — district-tsa — provincial-tsa. However further in connection with a shortcoming to lay down. stationary institutions, doctors and other medical staff this structure did not receive consecutive and universal implementation.
The question of free treatment of patients was a subject of bitter struggle between owners of zemstvoes and the advanced medical figures. Costs of zemstvoes of health care increased (in 1871 4,5 kopeks, in 1890 — 20,4 kopeks, in 1904 — 56 kopeks were per capita spent), but bosses of zemstvoes aimed to shift these expenses on shoulders of peasants. So, substantially they became covered by «subear collecting» from peasants. Except the general subear taxation for territorial needs, in a number of zemstvoes the special payment for hospitalization, a doctor's advice, the released medicine, ware, the recipe, etc. was raised. In different provinces and in different counties of the same province payment of these of «medical services» was various. Despite long-term fight of the advanced territorial doctors, for years of existence of zemstvoes completely free help was carried out only in a small part of provinces and counties.
A role of public medicine in formation and development of territorial medicine. On a wave of a revolutionary situation of the end of the 50th — the beginnings of the 60th of 19 century developed characteristic features of the Russian public medicine (see), exerted considerable impact on formation and development 3. the m, philosophy a cut were theoretically developed by the advanced doctors and progressive public circles even before introduction of a zemstvo. An essential role in development and improvement of philosophy 3. the m was played by progressive medical periodicals (see) — «The Moscow medical newspaper», «Doctor», «The Russian doctor», «The magazine of society of the Russian doctors in N. I. Pirogov's memory», «The public doctor», etc. also the advanced medical societies — «Society of the Russian doctors in Moscow», «Society of doctors in Kazan», «Society of the Russian doctors in N. I. Pirogov's memory». Progressive professors-physicians — P. I. Dyakonov, A. V. Korchak-Chepurkovsky, V. F. Snegirev, N. F. Filatov, F. F. Erisman, etc. were closely connected with territorial doctors and promoted improvement of territorial medical business. The circle of territorial doctors left a group of large representatives of separate medical specialties: surgeons S. I. Spasokukotsky, A. G. Arkhangelskaya; ophthalmologist V. A. Shafranovsky; psychiatrist V. I. Yakovenko and many others. Essential value in development 3. m had provincial and district congresses of territorial doctors. The first provincial congress of territorial doctors (The Tver province) was convened in 1871. On all territorial provinces till 1913 378 provincial congresses of territorial doctors took place (in addition to special congresses and meetings on fight against cholera, etc.). Special role in the history 3. m played congresses of doctors N. I. Pirogov's memory (see. Pirogovsky congresses ).
Pirogovsky's government about-va actually became the ideological leader 3. m. At the 1st Pirogovsky congress its chairman N. V. Sklifosovsky defined the territorial doctor as «the main figure among the Russian doctors». Also generally territorial doctors were a kernel of public medicine; at Pirogovsky congresses they had an opportunity to establish connection with the largest representatives of a scientific world — S. P. Botkin, his pupils S. S. Korsakov, A. A. Bobrov, G. N. Gabrichevsky, etc. Main stages of development medical dignity. affairs in zemstvoes found reflection in works of Pirogovsky congresses.
Formation of the sanitary organization in zemstvoes of X. Territorial justices, calling on service doctors in the first years of existence of a zemstvo, meant their exclusively medical activity. However heavy dignity. living conditions of country people, high incidence, mortality and hl. obr. epidemics forced zemstvoes to pay attention and a dignity. to questions. «Society of doctors in Kazan» one of the first among public organizations tried to create territorial a dignity. bodies. The chairman of society A. V. Petrov considered that the main premises for treatment of «public diseases» and increase in level of «public health» is «comprehensive study in the medical relation of areas..., studying of painful forms in connection with local conditions of their origin and development». Members of «Society of doctors in Kazan» and A. V. Petrov's pupils were given a dignity. doctors — I. I. Molleson, E. A. Osipov, N. I. Tezyakov, etc. A big contribution in territorial a dignity. work was brought also by P.F. Kudryavtsev, I. A. Dmitriyev, etc. I. I. Molleson, first domestic dignity. the doctor, suggested to make a dignity in 1871. inspection of the Perm province, however the offer did not find support of a territorial justice. Under the leadership of F. F. Erisman the Moscow provincial zemstvo carried out in 1879 — 1885 the first comprehensive (complex) a dignity. - a gigabyte. inspection and the description of 1080 industrial enterprises of the Moscow province with total number of working 114 thousand people what fundamental work in 19 volumes was result of. Organization dignity. services in zemstvoes occurred generally under pressure of such force majeure as threat of distribution of epidemics. Up to the end of the 90th years separate attempts of creation a dignity were made. institutions; they arose at threat of epidemics, and then were again closed. Only gradually, with great difficulties it was created a dignity. the organization, positions a dignity appeared. doctors. According to the full developed scheme of the sanitary organization a provincial dignity. the council consisting of territorial vowels (elective) and doctors, submitting to a provincial territorial justice formed provincial sanitary bureau, to-rogo the doctor who was actually directing everything a dignity was at the head. - protivoepid, business. The doctor-statistician, the doctor on smallpox vaccination and epidemiologists had to be a part of provincial sanitary bureau. The bureau had to publish medical and sanitary chronicles or reviews, as a rule, monthly (however their frequency was various in different zemstvoes) and to convene provincial congresses of doctors in coordination with a provincial territorial justice. The provincial sanitary bureau also directed district sanitary councils, to it was podvedomstven special body — sanitary guardianship. District dignity. doctors and local sanitary councils were subordinated to district sanitary councils.
Developed territorial a dignity. doctors scheme dignity. the organizations it was thought well over and could provide at full implementation development a dignity. affairs. However to work territorial dignity. bodies which formation only began and took place in the hardest conditions, stirred that territorial a dignity. bureau and separate dignity. doctors were forced because of underdeveloped network of medical institutions and shortage of medical staff to undertake, in addition to sanitary, also medical and organizational duties. Loaded by these duties territorial a dignity. doctors had no opportunity to fully get a dignity. - a gigabyte. qualification. Gigabyte. and bacterial, laboratories in zemstvoes or were not at all, or they were available in insufficient quantity and were badly equipped. Completing dignity. doctors went slowly and extremely unevenly. In the years of reaction after the revolution of 1905 a number of zemstvoes upon the demand of governors and partly on own initiative liquidated a dignity. the organizations, the dignity dismissed. doctors as «unreliable». The threat of epidemics forced to recover later a row territorial a dignity again. organizations. By 1913 more or less full a dignity. the organizations were available in 18 of 34 territorial provinces. Despite considerable distribution of epidemics in the country, in zemstvoes only 32 epidemiologists worked, and in 17 their provinces was not absolutely. Medical and sanitary chronicles (or reviews, leaves) published 24 zemstvoes from 34.
A special role in the organization and development medical - a dignity. affairs in zemstvoes played a dignity. statistics — «the only rationale of our public sanitary actions» (F. F. Erisman). The government statistics published by medical department was absolutely doubtful, «a continuous tall tale», by I. I. Molleson's definition. Territorial doctors gradually developed methods a dignity. - statistical work, the general and child mortality, incidence of the population, distribution of epidemics was studied. Questions dignity. statistics stood on all Pirogovsky congresses, starting with the first (1885, Ue. E. Jansson's report). The circle of territorial doctors left the largest specialists in the field of statistics — S. M. Bogoslovsky, P. I. Kurkin, E. A. Osipov, etc. Studying of incidence of the population demanded first of all exact statistical data. The philosophy formulated by E. A. Osipov in the report presented by the provincial sanitary commission to the Moscow provincial territorial meeting (1875) said: «Rational territorial medical assistance should be considered only such which not only appears doctors, but also correctly them is registered that in such way reliable material on morbidity of the population accumulated». V. I. Lenin in the works («An agrarian question in Russia by the end of the 19th century», «Development of capitalism in Russia», etc.) gave sanitary and statistical researches of territorial doctors of N. I. Tezyakov, P.F. Kudryavtsev, etc. on studying of living conditions of agricultural workers, highly appreciating these works. So, he considered that N. I. Tezyakov's research «... raised an edge of the veil covering working conditions in rural zakholustyakh» (V. I. Lenin, Half-N of SOBR. soch., 5th prod., t. 3, page 242). At the same time V. I. Lenin criticized a number of mistakes of the doctor D. N. Zhbankov and others for the wrong use of average statistical figures in works about seasonal works, etc. V. I. Lenin noted: «Force created by a zemstvo and brought considerable (compared with bureaucracy, of course) advantage to the population of medical and statistical institutions is sufficient to paralyze the charters fabricated in the St. Petersburg offices» (V. I. Lenin, Half-N of SOBR. soch., 5th prod., t. 5, page 49).
In 1894 at the initiative of the territorial doctor A. P. Voskresensky at Pirogovsky society the constant «Commission on distribution of hygienic knowledge in the people» was created. The commission published the popular brochures, leaflets, slides devoted to hl. obr. to fight against infectious diseases in the village; doctors gave popular lectures on medical subjects, etc. Active part in the commission was taken by outstanding territorial doctors; since 1901, St. 15 years, A. V. Molkov directed it. Work of the commission was interfered by both material difficulties, and constant prosecutions of police and censorship.
Results of medical and sanitary activity in a zemstvo in a generalized view for the first time were presented abroad at the International hygienic exhibition in Dresden (1911), and also at the All-Russian hygienic exhibition in St. Petersburg (1913) and caused an unanimous appreciation. The main organizers of exposure territorial medical - a dignity. works were territorial doctors 3. G. Frenkel, P. I. Kurkin, S. N. Igumnov.
The main indicators of development of medical matter in zemstvoes reached in 40 years of existence 3. m (from 1870 to 1910), are given in the table.
However, despite growth of number of medical sites (530 in 1870 and 2686 in 1910) and local clinics (66 in 1870 and 1700 in 1910) and other shifts, average values cannot serve as criterion for evaluation of a condition of medical aid in zemstvoes. They strikingly differed in various territorial provinces. So, in 1870 in the Olonets province there were 3 medical sites, and in Tambov 29; in 1910 in Olonets lips. there were 31 medical sites, in Poltava 136. The area of the average medical site in 1870 equaled 1750 sq. versts in the Ryazan province and 37 500 sq. versts in the Olonets province, in 1910 — 450 sq. versts in the Moscow province and 5600 sq. versts in the Vologda province. Even if not to take into account of continuous not populated spaces, in 1910 the average area of the territorial medical site by more than two times exceeded the 10-verstny radius taken for norm in zemstvoes. In 1910 only in one Moscow province there were no independent infirmaries, and in Vyatka them was 153, in Perm and Poltava on 200 and so forth. Extremely neravnomernm there was also a distribution of doctors on provinces and in provinces on counties. In 1890 when in a zemstvo more than 1600 doctors worked, about 25% of all doctors were the share of 5 provinces — Moscow, Voronezh, Kursk, Poltava, Chernihiv.
Historical experience of development 3. the m shows the huge, carried-out in the most difficult conditions, creative work of territorial medics. The medical site which was the main organizational form 3. in m and her largest merit, it was recommended in 1934. The hygienic commission of the League of Nations to other countries for the organization of medical aid to country people. About it N. A. Semashko wrote: «Thus, the local principle for the first time applied in our country by territorial medicine in pre-revolutionary time had to receive the international approbation. The merit of use of this principle belongs to our country». The role 3 is extremely important. m in development of health care. The famous hygienist M. Ya. Kapustin emphasized: «Western Europe developed medical care in diseases preferential in the form of a personal record of the patient and the doctor serving to it, as craft or trade. The Russian territorial medicine was purely public business. The help of the doctor in a zemstvo is not personal service at the expense of the patient, is not as well the act of blessing, it is public service...». «Both the highest, and narrow interest of the territorial doctor consists in reduction of number of patients and duration of diseases. Problems of the treating medicine and hygiene go hand in hand in continuous communication here». The organizational forms developed 3. m, were substantially apprehended by urban medicine and factory medicine which began to gain more certain lines at a boundary of 19 and 20 centuries in connection with further development of capitalism, growth of the industry and the cities. At the same time 3. m it was powerless to solve a number of problems which only the state health system created after Great October socialist revolution (allowed to carry out see. Health care , Meditsina ).
The main indicators of development of medical matter in zemstvoes from 1870 to 1910 (according to the book 3. G. Frenkel «Sketches of territorial medical and sanitary business, SPb., 1913)
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M. M. Levitte.