THERAPY

From Big Medical Encyclopedia

THERAPY (Greek. therapeia treatment). In modern medicine the concept «therapy» is used in two major importances:

1) the area a wedge, medicine studying an origin, manifestations, diagnosis, treatment and prevention of diseases of internals — a synonym Internal diseases (see), internal medicine;

2) the general designation of so-called conservative methods of treatment, a cut coexists with the concept «therapy» of its initial enlarged sense meaning treatment in general (e.g., assessment of surgery as method of pathogenetic T.). Carry to conservative, in essence, all nonsurgical methods of treatment, in particular drugs (see. Pharmacotherapy ), including antibiotics, streptocides and other himiopreparata (see. Chemotherapy ), hormonal means (see. Hormonal therapy ); serums and vaccines (see Vaccinotherapy, the Serotherapy); natural and preformirovanny physical factors — climatotherapy (see), balneoterapiya (see), speleoterapiya (see), physical therapy (see), a barotherapy (see), cryotherapy (see), etc., including different types of ionizing radiation (see. Radiation therapy), a dietotherapy (see clinical nutrition) and also to lay down. influence by the word (see Psychotherapy), labor process (see. Labor therapy), special impact on reflexogenic zones (see. Reflexotherapy ), etc. Treatment and the prevention of diseases make a main objective of medicine. At the same time efficiency of T. depends on the level of development of medical science and on system and practice of health care (see), and finally — on the level of social and economic and cultural development about-va.

According to an orientation of therapeutic influence allocate etiotropic, or causal, T., directed to elimination of an etiology; pathogenetic T., i.e. impact on developments of a disease for the purpose of their interruption or easing; symptomatic T. — elimination of displays of a disease, burdensome for patient; the actions directed to recovery of the functions broken by a disease (rehabilitation), or their substitution (replaceable T.).

History

Origin of T. treats the prehistoric period and matches on time emergence at Neanderthal men of «the forming medicine» (see Medicine). Apparently, T. initially included use of medicinal plants, and it is possible, and means of animal origin, napr, an animal fat, and also use of such natural factors as mineral waters and to lay down. dirt. With emergence and development of a primitive community to lay down. functions begin to concentrate in hands of attendants of a cult, and during an era of ancient civilizations become business of the professional Aesculapians who were quite often coexisting with doctors priests. Treatment pursued tasks to alleviate suffering of sick (wounded) — to eliminate pain and other unpleasant feelings, and also to stop influence of the factors supporting a disease; thus it was put symptomatic and pathogenetic the saying quoted by A. Tsels was T. Programmny for school of doctors empiricists in 3 — 2 centuries BC: «Not that is interesting that causes a disease, and what eliminates it».

In a Hippocratic face the empirical medicine of ancient reached the top., In Hippocrates's collection (see. Hippocrates collection ) the arsenal of pharmaceuticals is presented, to-rymi the doctor of Ancient Greece had. Laxatives, diuretics, and also banks and bloodlettings were used preferential emetic. Principle T. was: «Opposite there is medicine for opposite». From Hippocrates there is also a formulation of one of the important principles T.: «Non nocere!», i.e. first of all do not harm (to the patient with treatment). Hippocrates saw a task of the doctor in helping the nature to get rid of a disease, to spare forces of a sick organism, he learned not to change drugs needlessly, to apply strong means only when less active T. does not give effect. The belief is that treatment is impossible without efforts of the organism, «because the nature without foreign instructions at anybody without studying, does due», makes distinctive feature of T. at Hippocrates and his followers, Along with pharmaceuticals, the quantity to-rykh was limited to only several tens, the important place in T. it was taken away a gigabyte. to recommendations, in particular diet. At Asklepiad who continued in 1 century BC of tradition of Greek medicine in Ancient Rome favourite to lay down. simple, natural measures were methods also: diet, movement, balneotherapy, grindings, etc. Rational approach of doctors of the Ancient world to a problem of a ratio of the theory and practicians T. it is reflected And. Tselsom: «Iatrotechnics arose... not as a fruit of theoretical reasons, and on the contrary, began to think of theoretical justification when methods of treatment were already open».

In 1 century AD P. Dioscorides systematized pharmaceuticals of a plant, animal and mineral origin, grouped St. 600 plants on morfol. to the principle. In its pharmacopeia an important role was played by aromatic plants, and also oils and ointments as outside means. The aloe as laxative, opium at cough and a diarrhea were popular; from means of animal origin, e.g., a liver of a donkey at epilepsy; from drugs of a mineral origin — sulfur etc. P. Dioscorides's composition «About pharmaceuticals» served as a handbook on pharmaceutical science up to 16 in, a certain way of preparation of drugs is connected With a name of the largest Roman doctor K. Galen (see Galenova drugs). The Arab medicine, having used achievements of alchemy, enriched T. the pharmaceutical stock and medicines received in the chemical way put into practice compounds of mercury and caustic silver. The major role in development of rational T. played works of the great doctor and thinker of the East Ibn-Sina, to-ry offered the system of testing of effect of medicines including not only observation at a bed of the patient, but also an experiment on animals, indicated the need identifications of side effects, and also interactions of drugs. To further development of chemistry as bases of medicinal T. Paracelsus — the founder of yatro-chemistry promoted (see). Thanks to its works as drugs mineral substances and mineral waters began to be applied widely; he developed methods of allocation of an effective agent from herbal remedies.

However achievements of certain outstanding doctors could not change the general level to lay down. medicine of that time, and T., as a rule, it was a little effective at a bed of the patient. In 17 century the famous Leiden anatomist and the practicing doctor, the head of yatrokhimichesky school Silvius [F. Sylvius (de le Boe), 1614 — 1672] in traditions of humoral pathology reduced all variety of diseases to two groups — one are connected with education «acid», and others — with formation of «alkaline causticities». Thus, the seductive way of simplification of treatment — administration of either alkalis, or acids opened. In turn, S. Santorio and other representatives of a yatrofizika (see. Yatromekhanika ) as a theoretical basis of T. put forward mechanistic ideas of an organism as sets of pumps and levers, press and millstones and reduced treatment to sudorific measures, etc. Bloodletting as medical and even preventive method gained universal distribution, abuse of it reached to the point of absurdity: neither pregnancy, nor infantile age of the patient could save from this procedure, edge even in the first half of 19 century quite often served as a proximate cause of death of the patient.

A protest against sterile theorizing, an appeal to replace it with impartial medical observation the bed of the patient had, in essence, all activity of «the English Hippocrates» of T. Siden-gama, to-ry in 17 century proclaimed again that a task of the doctor — to promote salutary forces of an organism; it is not necessary to be fond of medicinal T., when there are no specific remedies: «the experienced physician shall abstain sometimes from any treatment, and in other time to use very vigorous means...». It treated malaria bark of a cinchonic tree, an anemia — iron preparations, gout — and was quite often limited to a diet and gymnastics in to lay down. to practice by psychotherapeutic influence.

In the middle of 19 century when obvious progress in development of physical methods of a research of the patient and evidence-based intravital diagnosis came into conflict with explicit lack of evidence-based T., reaction to the reigning polypragmasy (unjustified appointment to the patient of at the same time many drugs) accepted at Y. Skoda and other prominent representatives of new Vienna school an extreme form — so-called therapeutic nihilism: «We can distinguish, opi-sal and understand a disease, but we shall not even dream of an opportunity to influence her any means».

Only in the second half 19 — the beginning of 20 century in connection with rapid progress of natural sciences, in particular theoretical medicine (a patomorfologiya, experimental medicine, bacteriology) and technicians, formation of evidence-based T begins. Further rapid development of chemistry, physics, the equipment, biology, the scientific and technological revolution which captured the world in the second half of 20 century reweaponed and transformed T. Possibilities of modern T. look boundless. Endoscopy and ultrasound, pressures chamber and radioisotopes, molecular biology and immunochemistry made available for to lay down. interventions the deep-lying bodies and fabrics and intimate mechanisms of life activity. On agenda — treatment inf. the center in the bronchopulmonary device not only local introduction of antibiotics, but also the immunocompetent cells multiplied in culture of fabric taken and returned in an organism by means of the bronchoscope; out-patient, with preservation of working ability of the patient, chemotherapy of hemoblastoses; broad use of artificial pacemakers of heart, hron. hemodialysis, hemosorption, correction of «chromosomal mistakes» etc. Streptocides, antibiotics, hormonal drugs, cardiac glycosides, cytostatic and psychotropic drugs, vaccines and serums brought closer the therapist to the surgeon, both by efficiency, and on possible negative effects to lay down. interventions.

Increase in an arsenal of modern T., especially rough production pharmakol. drugs, increased need of comparative assessment of effect of different drugs and not medicinal ways of treatment and the requirement to validity of their use. Up to 19 century therapeutic effect of medicines was tested on the patient, and experimental check pharmakol. drugs it was carried out on healthy animals, i.e. in the conditions far from those, to-rye are inherent in activity of a sore human body. Only in 20 century the idea of need of experimental T which is put forward still by K. Bernard., without cut to lay down. practice is often blind, became conventional. Its successful development by much is obliged to a method of reproduction patol. processes at animals, i.e. to creation of pilot models of diseases (see. Model of a disease ), fruitfully developing in the USSR I. P. Pavlov, A. B. Fokht, N. N. Anichkov, N. D. Strazhesko's schools, A. L. Myasnikova and other pathologists and clinical physicians. The technique of studying to lay down. actions of various means and ways, applied in experimental therapy and experimental pharmacology (in development it in the USSR a special role was played by N. P. Nravkov's school), submits to the same laws, as other methods of experimental sciences.

Features of modern T. ratios symptomatic force to consider in a new way a problem, pathogenetic and et Potro is a lot of treatment.

Symptomatic T. — the coeval of medicine also pursues the same, as a millennium ago, problems of elimination or reduction of specific displays of a disease simple and clear to each patient. In to lay down. to practice situations when it is necessary to eliminate a symptom of a disease irrespective of its reason and a pathogeny as it inflicts on the patient strong suffering are frequent and worsens the course of a disease. Can be an example the exhausting dry cough or vomiting of pregnancy, pains on the course of a trifacial at neuralgia, etc. Symptomatic T. remains the unique help at nekurabelny forms and stages of diseases (e.g., at an inoperable carcinoma of the stomach). However efficiency of the modern symptomatic means yielding bystry and notable result (killing pain and alarm, allowing to fall asleep at sleeplessness, to reduce temperature at fever etc.), quite often creates illusion of treatment of the disease and additional difficulties for timely diagnosis of diseases. So, elimination of acute abdominal pains by means of analgetics, especially narcotic, can complicate recognition of an acute appendicitis and other diseases demanding an urgent operative measure and also receiving consent of the patient to this intervention. Besides, the symptom of a disease can be expression of the defense reaction of an organism directed to fight against a disturbing factor, or manifestation of the compensatory reaction directed to recovery of the broken functions (e.g., fever at inf. process, vomiting at hit in a stomach of toxic agents, overbreathing at acidosis etc.). In such cases full elimination of a symptom can have tragic effects. E.g., suppression of function of a respiratory center morphine at an asthma at the patient with respiratory insufficiency can lead to a lethal outcome. Possible dangers of vigorous symptomatic T. caused partial failure from it at certain stages of treatment (e.g., from anesthesia before specification of the diagnosis and making decision on operational or other radical way of treatment).

Pathogenetic T. relies on knowledge of developments of a disease. So, knowledge of processes of a thrombogenesis and their role in a pathogeny of a myocardial infarction, thrombophlebitis, thrombosis of mezenterialny arteries, etc. allowed to create and apply as means of pathogenetic T. at these diseases anticoagulants and trombolitik. Choice of this or that medicinal or other way of pathogenetic T. depends on an origin and character patol. process. At a thyrocardiac myocardial dystrophy of pathogenetic T. elimination of hyperfunction of a thyroid gland by means of mercazolil or other means is (e.g., a radioiodine or operational removal of a part of gland). To pathogenetic T. kollagenoz use of immunodepressants etc. belongs.

Pathogenetic T. includes methods of tsitostetichesky, beam and operational treatment and, unlike symptomatic T., quite often arouses mistrust and a protest of the patient. The doctor shall be able to explain to the patient, having given lechebnodiagnostichesky arguments, need of the offered intervention and to convince of its logicality.

Border between pathogenetic and symptomatic T. it is clear not always since elimination of any symptom of a disease can be accompanied also by elimination of a certain pathogenetic link. E.g., elimination of hypostasis of fabric diuretics at heart failure (symptomatic T.) can reduce heart failure due to reduction of load of heart (pathogenetic T.). For stopping burdensome for a sick symptom it is the most reasonable to influence the link of a pathogeny which was a proximate cause of emergence of this symptom. So, at an asthma inhalation of oxygen, but more effective measures influencing on patol is useful. process, the Crimea an asthma is caused: removal of an exudate at pleurisy, use of cardiac glycosides at a circulatory unefficiency etc.

A specific place is held by replaceable T., compensating insufficient function. Most often it consists in administration of the corresponding physiologically active agent: salt to - you at a gastric akhiliya, B12 vitamin at pernicious anemia, insulin at a diabetes mellitus. Hormonal therapy at endocrine insufficiency — a classical example of replaceable pathogenetic treatment. However in the second half of 20 century progress in studying of functions of a hypophysis, adrenal glands and other closed glands and their role in a pathogeny of not endocrine diseases led to enrichment of an arsenal to lay down. means many new hormonal drugs (AKTG, a cortisone, Prednisolonum, Aldactonum, etc.), to-rye are effective at treatment not only endocrine frustration, but also a number of internal and other diseases where their pathogenetic to lay down. action has no replaceable character. For the purpose of substitution of function of the struck body apply also stimulation of similar function of other body or artificial organs, napr an enteroclysis or a hemodialysis at insufficiency of secretory function of kidneys.

Etiotropic, or causal, T. consists in elimination of an efficient cause of a disease — removal of poison of an organism at poisonings, elimination of a nevrotiziruyushchy stres-weed factor at neurosis etc.; ancient ways of exile of worms also were in essence reception of causal treatment. Still M. Ya. Mudroye noted: «In diseases it is necessary to begin treatment with a root, that is from the reason then its branches or attacks of a disease in itself will wither and will be gone». The requirement at treatment of any patient to begin with causal T. — «Sublata causa tollitur effectus» (with the termination of the reason it is terminated and) is logical, but is not always feasible.

Ample opportunities in treatment inf. diseases etiotropic T. received with development of the directed synthesis of himiopreparat in 20 century. However in 16 century the reformer of medicine Paracelsus applied the mercury offered for this purpose at the end of 15 century to treatment of syphilis. In 17 century the authority T. Sydenham promoted that the European medicine recognized bark of a cinchonic tree as means of the choice at treatment of malaria («an empirical rudiment of chemotherapy», according to B. E. Votchal). In 1891 D. L. Romanovsky by practical consideration proved and formulated the concept of chemotherapy. But only with opening at the beginning of 20 accusative by Ehrlich of salvarsan and in the 30th G. Do-magk — bacteriostatic action of sulfanamide drugs there came the era of antimicrobic chemotherapy (see). Its blossoming in the second half of 20 century is connected with extending to lay down. use natural, semi-synthetic and synthobiotics.

The chemotherapy armed the doctor against almost all causative agents of infectious and parasitic diseases, caused falloff of a lethality at them and a possibility of successful treatment of diseases, to-rye earlier inevitably conducted the patient by death (e.g., tubercular meningitis). At the same time possibilities of etiotropic T. inf. it is not necessary to absolutize diseases. In the methodological plan it would be reflection of a monokauzalizm (see) — the directions of the medical thinking characteristic of a so-called bacteriological era in medicine (arose at a boundary of 19 — 20 centuries) which was obviously revaluating a role of a bacterial factor in an etiology and a pathogeny of diseases of the person and in this regard been insolvent, as well as any especially mechanistic approach to problems of pathology. For a variety of reasons possibilities of etiotropic T. are limited. First, after elimination of the specific reason secondary patol. process can continue, the remained disturbances of functions and damage of fabrics demand the corresponding pathogenetic and symptomatic treatment, sometimes long. Secondly, against the background of antibacterial T. process of development of antibodies can be detained that interferes with formation of necessary immunity. Thirdly, though etiol. factor of a row inf. diseases it is studied, effective remedies of their etiotropic T. it is not found (e.g., against a viral hepatitis and many other viral infections). Possibilities of etiotropic T are even more limited. at not infectious diseases. The etiology of many, including most widespread diseases defining the main type of pathology in economically developed countries is multifactorial; the costs of a modern way of life which are adversely influencing an organism act as the total reason of such diseases. The hypertension, atherosclerosis and a myocardial infarction («an ominous triad», according to A. L. Myasnikov), neurosises etc. are that. Causal T. at these diseases — correction of certain links in a difficult complex of work and life (e.g., an exception of psychoemotional retension and salty food at an idiopathic hypertensia, excess food at obesity and a diabetes mellitus, smoking at vasomotor spasms, etc.) — it is supplemented medicamentous, operational and other methods of pathogenetic treatment. In many cases the changed reactivity of an organism acts on the foreground among etiologies while external etiol. factors are various, i.e. a disease, according to N. D. Strazhesko, polietiologichno, but monopatogenetichno. So, e.g., at bronchial asthma as an external etiol. a factor the offending allergens which are contained in pollen of plants or in means of house cosmetics, the autoallergens connected with existence in an organism hron can act. the infectious and inflammatory center, etc., and the essence of a disease comes down to the certain pathogenetic reaction of an organism which is shown a bronchospasm. Respectively specific desensitization is method of pathogenetic, but not etiotropic T.

Restriction of indications to etiotropic T., first of all chemotherapy, follows also from danger given to lay down. interventions. The first steps of chemotherapy showed that salvarsan not only possesses powerful to lay down. effect, but also causes in some cases heavy (sometimes deadly) damages of a liver. Many bacteriostatic drugs were at the same time and cytostatic. The individual intolerance of these drugs caused by genetic defect came to light. If concerning, e.g., streptocides it can be predicted, then concerning levomycetinum — it is impossible, and the aplastic syndrome which developed as a result of prolonged treatment by levomycetinum leads to a lethal outcome in 90% of cases that limits use of this valuable drug. Possible complications of antibacterial T. are not limited to such undesirable effects as intoxication, a sensitization, etc., and include also effects of ecological disruptions of a macroorganism with the being in it and bacterial flora, necessary for its activity. Prolonged use of antibiotics of a broad spectrum of activity can cause development of dysbacteriosis (see), candidiasis (see), cases of development of heavy staphylococcal enteritis are noted. Other danger is that the organism can fall «a victim of the microbes» which became resistant to antibiotics (see. Medicinal stability of microorganisms): the sepsis caused by a strain of staphylococcus, resistant to antibiotics, can become the price for treatment from a furunculosis. Side effects are observed at treatment by antibiotics of any groups: penicillin causes sometimes an acute anaphylaxis at the first introduction, tetracyclines can cause toxic dermatitis with total amotio of epidermis, semi-synthetic cephalosporins in the presence at the patient of the latent renal failure — blockade of kidneys. Thus, though antibiotics and streptocides remain the safest weapon of the doctor in fight against an infection, it is necessary to resort to this weapon only in that case when the infection is dangerous to an organism and an organism, according to the doctor, can not cope with it. Ratio of symptomatic, pathogenetic and etiotropic T. in each separate case of a disease variously also shall be rational. The complex T is most often carried out., directed both on the reason, and on a pathogeny of a disease and, if necessary, on elimination of its separate manifestations.

Everyone to lay down. the specialty has the features of T. At the same time its general provisions and the principles remain invariable for the doctor of any specialty. So, needless to say, that T. there should not be more dangerous, than a disease. At inoperable forms of tumoral diseases, e.g., beam T. and chemotherapy at any risk connected with their use are justified as without treatment the lethality makes 100%. From possible remedies the choice of the safest and at the same time the most effective is necessary for this patient. Therefore it is important to define criteria of efficiency of T. Naznachaya T., the doctor expects its efficiency; if anticipation did not come true, it changes means or the direction T., and having convinced and in their inefficiency, sometimes reconsiders correctness of the diagnosis. Always it is necessary to consider, that reaction of an organism of the patient is individual not only on a causative factor of a disease, but also on to lay down. means therefore careful overseeing by a condition of the patient is important during T. Effect of the medicine can change as a result of a renal failure, a liver, blood circulation, absorptions in went. - kish. path, etc. Influencing organ changes, to-rye can sometimes decide destiny of the patient, it is impossible to forget that treatment eventually depends on a condition of a complete organism. One of the reasons of failures of T. co-administration of the means opposite on action on the broken function, or chemically incompatible drugs, and also frequent change of drugs is.

In the Soviet health care the organization of treatment of many diseases is under construction as step-by-step T., including consecutive treatment in policlinic,-tse, a dignity. - hens. establishment or in rest house, dispensary observation and treatment. Not only treatment of patient per se, but also medical rehabilitation (see) with recovery of its working capacity, partial or full is provided to these. Along with planned T. the theory, practice and the organization urgent, or urgentny, are developed by T., carried out according to vital indications, i.e. at diseases and patol. states, directly life-threatening person. Necessary premises of definition of such indications — timely recognition patol. states, the correct predictive assessment of the revealed symptoms and functions of vitals and classification of a state, life-threatening (shock, an acute abdomen, a coma etc.). As at such states medical aid shall be urgent since the delay can lead to the death of the patient, the doctor, as a rule, makes the decision, despite obviously incomplete information, often before establishment of the diagnosis of the main disease, napr, makes a laparotomy at an acute abdomen. Especially for carrying out T. according to vital indications are created system of emergency medical service (see), in-tsakh — departments of intensive observation and resuscitation (see) where measures for rescue of patients at damage of heart are carried out, a brain, at poisonings and injuries. In the conditions of accidents, mass defeats, etc., when there is no an opportunity to give urgent medical assistance by all victim, an important role is played by T. on the basis of most and mutual assistance (see the Self-care and mutual assistance) that demands training of the population of first aid (a stop of bleeding, a transport immobilization of extremities at changes, an artificial respiration and the closed cardiac massage etc.).

Unlike an urgent self-care at extreme situations self-treatment of diseases of means of modern T. it became more dangerous than when that was before; to explain to the population inadmissibility it — important forgiving sanitary education (see). However it does not exclude active participation of the patient in treatment: at many it is long the proceeding diseases of the patient at the advisory guide and periodic control of the doctor accepts the appointed drugs, being guided by subjective and objective indicators, to-rye are chosen as the doctor as criteria of a dose and effect to lay down. means. The out-patient T is quite so carried out. number of diseases of the tumoral nature, in particular leukoses. In nek-ry cases of the patient studies the equipment to lay down. injections also administers to itself the drug appointed by the doctor parenterally (e.g., drugs of insulin at a diabetes mellitus).

Planned T. provides rendering to the patient all possible volume qualified to lay down. the help, including, if necessary, specialized medical care (see). Scheduling of T. begins with definition of indications to treatment of the patient and assumes reflection of basic elements to lay down. strategy and tactics of the doctor. Indications are established on the basis of the diagnosis of a disease and the analysis of the data obtained at inspection of the patient. Traditionally distinguish the causal indication (indicatio causalis) reflecting a possibility of etiotropic T.; the indication of a disease (indicatio morbi) — justification of pathogenetic T.; the symptomatic indication (indicatio sym r thorn at i-sa) proving need of symptomatic T., and also the vital indication (indicatio vitalis) assuming to lay down. the measures directed to rescue of life of the patient.

Consecutive clarification of need and a possibility of a causal, pathogenetic or symptomatic treatment is based on the exact diagnosis of a disease and the analysis of its manifestations at this patient. In this analysis it is necessary to establish causal dependence of the found symptoms from defined patol. processes in an organism, i.e. a pathogeny of a disease. Only in such way it is possible to find a decisive link, the subject to lay down. to influence. Before establishment of the diagnosis and the choice of criteria of efficiency of medicine or a complex to lay down. actions to begin T. it is impossible. So, e.g., Prednisolonum which is mistakenly appointed concerning an estimated system lupus erythematosus can be the reason of hematogenous dissimination latentno of the proceeding tuberculosis; the cytostatics appointed concerning the expected immune conflict can become a source of mutations in the hemopoietic cells and development of an acute leukosis. Use of such means can be more dangerous, than failure from T. before clarification of the diagnosis. Besides, T. before diagnosis of a disease can interfere with the solution of a diagnostic task in general. E.g., the glucocorticoid hormones used in connection with a long hyperthermia, an arthralgia, a pleural exudate etc., liquidating these displays of a disease, do diagnosis of a tumor or a general disease of connecting fabric impossible before a recurrence when the disease can be not giving in to lay down any more. to influence. The high degree of responsibility connected with justification of T. the diagnosis of a disease, assumes timely use of all methods of inspection of the patient, necessary for diagnosis (that demands scheduling of inspection), demands clinical erudition and thinking, if necessary — medical consultations.

After definition of the general indications and the place of treatment (in a hospital, in policlinic, at home, etc.) the doctor draws up the specific plan of therapeutic actions, proceeding from a form of a disease, features of its current and possible effects, a condition of the patient, existence of the accompanying diseases and considering real opportunities of use of a certain method T. in these conditions. The plan includes measures of the prevention of possible complications both the disease, and the carried-out treatment, napr, purpose of anticoagulants for the prevention of thromboembolisms.

Pharmaceuticals are appointed taking into account dependence to lay down. effects of drug from its dose and a ratio of medical and toxic doses, to-rye at a number of drugs, napr, at cardiac glycosides, are quite close. Possible toxicity of drug is considered on a so-called therapeutic index — the relation of a toxic dose to medical. Define also a way of introduction of medicine depending on features patol. process and pharmacokinetics of drug, consider rules of cancellation of this means.

In respect of complex T. find reflection also types and terms of carrying out not medicinal ways of treatment — physical therapy, a dietotherapy, etc., and also recovery T. (to lay down. physical culture, massage, sanatorium therapy etc.).

Carrying out T. even by the most effective modern medicinal and physical methods it has to be combined with the maximum use of opportunities of psychotherapy. Up to the beginning of 20 century in an arsenal of medicine there were very few efficient drugs, and the main place in T. occupied medical council. Lech. progress of representatives of traditional medicine (see) the past and traditional medicine of the countries of Africa, Asia and Latin America considerably is explained today by art of psychotherapeutic impact on the patient.

Rational the wedge, the concept always considers both somatic, and mental symptomatology during the scheduling of T., because at any disease mental balance is broken (or it can be broken). Psychotherapeutic influence of the doctor begins with his first contact with the patient. The attentive and benevolent relation to complaints of the patient in itself gives to it relief. According to V. M. Bekhterev, «if it do not become easier for the patient after the conversation with the doctor, then this is not the doctor». It is inappropriate to share with the patient the doubts in correctness of the diagnosis; the doctor solves these problems without participation of the patient. Specification of the diagnosis in some cases can, and sometimes and shall be postponed until the end of comprehensive inspection of the patient, but at the same time from the very beginning the doctor should inspire in the patient hope for recovery.

Problems of modern T. are defined by change of nature of pathology in economically developed countries, differentiation a wedge, disciplines, the accruing technicalization of medicine, features of modern medicinal and other means and methods of treatment allowing to speak about «drama therapy».

Complex of complex problems of modern T. it is considerably generated by broad use of quickly accruing number of active pharmaceuticals and other methods of effective T. Evolution of ways of treatment of the majority of diseases within many centuries was not followed by emergence of the drugs which are actively influencing disease. In 19 century it is mute. the clinical physician B. Naunin spoke: «I would not like to be a doctor if there was no digitalis»; the doctor of the second half of 20 century does not think of T. without penicillin, insulin, Prednisolonum, nitroglycerine, Reserpinum etc. Intensive growth of quantity of drugs in 20 century (so-called pharmaceutical explosion) created an additional problem: the more drugs, the it is more difficult to find out a useful and adverse effect of each of them and the problem of assessment of effect of medicines is more urgent, edges in the methodical relation it is very difficult. Special importance wedge, studying pharmakol. means in the conditions of modern T. predetermined formation of the new section of medicine — the clinical pharmacology studying pharmacokinetics — absorption, distribution, exchange and removal of drugs (see Pharmacokinetics), the mechanism pharmakol. effects of the medicine in an organism of the patient, side effects of pharmaceuticals (see) and developing a rational technique to lay down. uses of drugs (see Pharmacology clinical).

The multilateral effect (polipotentnost) of medicines including side effects caused urgent for modern T. a problem of control, including international, over release and use of pharmaceuticals and prevention of the complications caused by treatment, including a medicinal allergy (see) and other manifestations of side effect of pharmaceuticals (see). According to WHO data, e.g., in only one 1974 more than on 8,5 thousand drugs is registered apprx. 85 thousand cases of adverse reaction.

The reasonable aspiration to increase efficiency of T. by use of new means and a combination of drugs it is not always supported with full knowledge about the effect of drugs and expediency of their combination that leads to a polypragmasy. In the conditions of «drama therapy» of 20 century and the competent specialist the doctor arguing by the principle is not insured from complications of the treatment appointed by it, and: «still to give to the patient?» — represents for it real, and sometimes and danger of death.

Fashionable to lay down. means and methods (within only the last several decades tremendous success without any therapeutic effect lysates and replanting, means against aging — soda bathtubs, the «Bulgarian» curdled milk, novocaine, magnetic bracelets at arterial hypertension had, «run from a heart attack» and various forms of starvation, мноя^ество «anticarcinogenic» means, use of services of psychics, etc.) quite often are modern reflection of a dream of the panacea accompanying medicine throughout all its history.

Complex problems of T. are connected with pathomorphism (see) — the change of a course of a disease caused by influence of environmental factors, evolution of causative agents of diseases and improvement of methods of treatment. So, the acute dysentery caused by Grigoriev's shigellas — Shigi, with heavy a wedge, a current, meets seldom, but the form prevailing now caused by Zonne's shigella quite often passes in hron. dysentery; acute polyarthritis ceased to play a role of a typical initial syndrome of rheumatism, and primary rheumatic carditis often proceeds with erased a wedge, manifestations that complicates timely diagnosis and treatment. Change of an immunoreactivity under the influence of medicinal treatment is noted, life-threatening reactions to administration of medicinal substance, e.g. an acute anaphylaxis (see), a serum disease became frequent (see). Lethal outcomes at bronchial asthma in connection with excess use of modern bronchodilators and glucocorticoid hormones became frequent.

Important problem of modern T. it is connected with demographic factor — a postareniye of the population. Though the share of elderly people made in general across the USSR (1975) about 13%, over a half of the medicines consumed in the country was the share of them. At the same time it is known that the effect of many pharmaceuticals at young and advanced age is not identical. At advanced age dangerous side effects of drugs can be observed more often. So, naira., hypnagogues in «average» doses can cause emergence of heavy disorders of breath. Development of rational schemes of medicinal T. at advanced and senile age — an urgent task geriatrics (see).

A peculiar problem is made by out-patient use of drugs in the conditions of technical progress. E.g., purpose of hypnotic drugs and psikhofarmakol can turn back transport accident. means not only to the faces tied with a traffic department but also pedestrians.

«Drama therapy» inevitably puts forward new problems of deontological character. The most important of them is connected with expansion of the circle of pathology called by iatrogenic diseases (see), to the Crimea all diseases caused by actions of medical staff, including use of pharmaceuticals belong (in wide value of this concept). Quite often choice of T. it is accompanied by risk of its possible complications. Only knowledge and experience of the clinical physician, high sense of responsibility for destiny of the patient help to make the correct decision in each case. At the same time the continuing branching a wedge, medicine — an inevitable consequence of scientific and technical progress — the doctor-klini-cyst conceals threat of substitution by the narrow specialist, to-ry always sees before itself the patient as a complete organism and the personality. Narrow specialization raised a question with new sharpness: to treat the patient or a disease? To treat according to specific features of the patient was the important principle T. both at Hippocrates, and at T. Sydenham, and at M. Ya. Mudrov («Not the disease takes medicine, and the patient»). They could treat the patient, but not a disease as to the second half 19 century were not and there could not be an evidence-based and developed classification and the nomenclature of diseases. Allocation of nosological forms on the basis of knowledge of an etiology, a pathogeny, a patomorfologiya («the place where the disease»), a wedge, semiotics, a current sits and probable results of treatment allows to carry out T. diseases. To treat not abstraction (nosological unit), and a certain disease at the specific patient, all-therapeutic preparation, development wide a wedge, thinking, strict observance of fundamentals of medical ethics is necessary for the doctor (see the Deontology medical, Ethics in medicine ).

In the course of T. the doctor shall explain to the patient need of observance corresponding a gigabyte. way of life. Repeatedly talking to the patient, it is possible to force it to refuse an addiction, napr, smoking, to convince him of obligation of a certain diet, work and rest. The important, and at times decisive place in respect of T. any disease borrows leaving (see) for the patient for the purpose of creation of the optimal conditions promoting treatment, restrictions of physical tension, barrier from mental traumatization. Careful, but timely transition from a dormant period and the sparing mode to usual life, and then to work makes an obligatory part of the plan of T. Treatment shall be organized taking into account its approximate duration, terms of temporary disability of the patient, need of the hospital mode or performance to lay down. procedures in house conditions, etc., the sequence (phasing) of use of forms T. (up to further dispensary observation). Successful treatment is result of activity not only the doctor, but also an average and the junior medical staff providing performance to lay down. appointments, observance of the mode and nosotrophy.

Despite complexity of the problems facing modern T., its progress is indisputable. As a result of scientific and technical progress, social and economic changes, achievements of medical science and health care indicators of the state of health of the population significantly improved, mortality, first of all the nursery decreased; average life expectancy in the USSR and some other countries reached or exceeded 70 years. The infectious and parasitic diseases which had mass distribution in the past and being the main reason, mortality by 70th 20 century lost the predominating role. On their place as the leading reasons of mortality cardiovascular and tumoral diseases moved forward. Their social importance and communication with so-called risk factors, including directly caused by change of a way of life and the habitat of the person put in the forefront questions of primary and secondary prevention (see Prevention, Prevention primary). The socialist health care with the principle of general availability inherent in it and free of charge medical aid and method of medical examination (see) creates all premises for implementation in scales of the country of precautionary T. cardiovascular, oncological, hron. nonspecific pulmonary diseases, a peptic ulcer and other noninfectious diseases which are ranking high in structure of incidence including with temporary disability. In the conditions of modern T. from new positions many questions of examination of working capacity, transfer into disability began to be considered. Use of highly effective means allows to try to obtain success at those forms of pathology where recently it was absolutely excluded. E.g., T. a lymphogranulomatosis, a horionepi-telioma cytostatic means allows to achieve in some cases recovery and recovery of working capacity even in the presence of the remote metastasises of a tumor.



Bibliography: Vasilenko V. H., Questions of doctoring, Rubbed. arkh., t. 45, No. 11, page 116, 1973; about N e, Vis medicatrix naturae (to a discussion about a disease), Klin, medical, t. 54, No. 9, page 18, 1976; Votchapb.E, Sketches of clinical pharmacology, M., 1965; Of l I z e r G., About thinking in medicine/, the lane with it., M., 1969; Kassirsky I. A. About doctoring, M., 1970; Kassirsky I. A. and Milevskaya Yu. JI. Sketches of modern clinical therapy, Tashkent, 1970; The Drug disease, under the editorship of G. Mashdrakov and P. Popkhristov, a per * with bolg., Sofia, 1976; Tareev E. M. A problem of iatrogenic diseases, Rubbed. arkh., t. 50, No. 1, page 3, 1978; Frolkis. B. Philosophy of modern therapy, Petrozavodsk, 1973; E l sh t e y N. V N. Therapists and specialization of medicine, Tallinn, 1973, bibliogr.


Century of X. Vasilenko, A. I. Vorobyov; V. I. Borodulin (ist.).

Яндекс.Метрика