Synthetic scheme of the pathogenesis of the disease. Pathological process, pathological condition
The pathological process is a combination of local and general reactions. occurring in the body in response to the damaging effect of a pathogenic agent. The development of the pathological process depends both on the etiological factor and on the reactive properties of the organism. The damaging agent can stop its action, and the pathological process develops in accordance with the program developed in evolution and inherited (for example, acute inflammation).
A pathological condition is a pathological process that develops more slowly. The painful disturbances observed at the same time are a little dynamic. They remain almost unchanged for a long time (years, decades). A pathological condition is often the result of a pathological process. So, inflammation of the cornea can result in the formation of a thorn that remains for life. A stomach ulcer (pathological process) may result in a scar and narrowing of the pylorus (pathological condition). The opposite is also possible, i.e., the transition of a pathological state into a pathological process. For example, a cancerous tumor may form at the site of a post-burn scar under the influence of carcinogenic factors.
The presence in the body of a pathological process or pathological condition does not mean the disease in its entirety. But this can happen if the body is weakened or the process becomes widespread and especially aggressive. For example, inflammation of the hair follicle - a furuncle - is a pathological process on the skin, but not a disease. The occurrence of multiple boils can give a detailed picture of the disease with fever, intoxication, etc.
Typical pathological processes develop according to the same basic patterns, regardless of the characteristics, cause, location, type of animal. In other words, typical, or typical, pathological processes are basically the same under various pathogenic influences, in various organs and in various animals - this is inflammation, fever, tumors, hypoxia, starvation, hyperemia, thrombosis, embolism. The fact that all animals, including humans, starve in the same way (mostly), react the same way to a lack of oxygen, that inflammation develops in all animals according to the same laws, indicates that all these processes have been formed in evolution and the possibility of their development is transmitted by inheritance. Of course, inflammation or tumors in different animal species have their own characteristics, but the task of pathological physiology is not to deal with details, but to find common signs and thus come closer to understanding the patterns of their development.
The main periods (stages) of the development of the disease
In the development of the disease, four periods (stages) are usually distinguished: latent, prodromal, the period of the height of the disease and the outcome, or the period of the end of the disease. Such a periodization has developed in the past with clinical analysis acute infectious diseases (typhoid fever, scarlet fever, etc.). Other diseases (cardiovascular, endocrine, tumors) develop according to other patterns, and therefore the above periodization is of little use to them. A. D. Ado identifies three stages in the development of the disease: the onset, the stage of the disease itself, and the outcome.
latent period(in relation to infectious diseases - incubation) lasts from the moment of exposure to the cause until the first clinical signs of the disease appear. This period can be short, as with the action of chemical warfare agents, and very long, as with leprosy (several years). During this period, the body's defenses are mobilized, aimed at compensating possible violations, to destroy disease-causing agents or to remove them from the body. It is important to know the features of the latent period when carrying out preventive measures (isolation in case of infection), as well as for treatment, often effective only in this period (rabies).
prodromal period- this is the length of time from the first signs of the disease to the full manifestation of its symptoms. Sometimes this period manifests itself brightly (croupous pneumonia, dysentery), in other cases it is characterized by the presence of weak, but clear signs of the disease. With mountain sickness, for example, this is causeless fun (euphoria), with measles - spots of Velsky - Koplik - Filatov, etc. All this is important for differential diagnosis. At the same time, the identification of the prodromal period in many chronic diseases is often difficult.
The period of pronounced manifestations, or the height of the disease, is characterized by the complete development of the clinical picture: convulsions with parathyroid insufficiency, leukopenia with radiation sickness, a typical triad (hyperglycemia, glycosuria, polyuria) in diabetes mellitus. The duration of this period for a number of diseases (croupous pneumonia, measles) is relatively easy to determine. At chronic diseases with their slow flow, the change of periods is elusive. In diseases such as tuberculosis, syphilis, the asymptomatic course of the process alternates with its exacerbation, and new exacerbations sometimes differ markedly from the primary manifestations of the disease.
Outcome of the disease. The following outcomes of the disease are observed: recovery (complete and incomplete), relapse, transition to a chronic form, death.
Recovery- a process that leads to the elimination of disorders caused by the disease, and the restoration of normal relations between the body and the environment, in humans - primarily to the restoration of working capacity.
Recovery can be complete or incomplete. Full recovery- this is a state in which all traces of the disease disappear and the body fully restores its adaptive capabilities. Recovery does not always mean a return to the original state. As a result of the disease, changes from the side of various systems, including immune
At incomplete recovery the consequences of the disease are expressed. They remain for a long time or even forever (fusion of the pleura, narrowing of the mitral orifice). The difference between complete and incomplete recovery is relative. Recovery can be almost complete, despite a persistent anatomical defect (for example, the absence of one kidney, if the second completely compensates for its function). It should not be thought that recovery begins after the previous stages of the disease have passed. The healing process begins from the moment the illness occurs.
The idea of the mechanisms of recovery is formed on the basis of general position about the fact that the disease is the unity of two opposite phenomena - the actual pathological and protective-compensatory. The predominance of one of them decides the outcome of the disease. Recovery occurs when the complex of adaptive reactions is strong enough to compensate for possible violations. Of the mechanisms of recovery, urgent (emergency) and long-term are distinguished. Urgent ones include such reflex defense reactions as changes in respiratory rate and heart rate, the release of adrenaline and glucocorticoids during stress reactions, as well as all those mechanisms that are aimed at maintaining the constancy of the internal environment (pH, blood glucose, blood pressure, etc.). d.). Long term reactions develop somewhat later and act throughout the disease. This is primarily the inclusion of reserve capabilities of functional systems. Diabetes mellitus does not occur when even 3/4 of the pancreatic islets are lost. A person can live with one lung, one kidney. A healthy heart can do five times more work when stressed than at rest.
Strengthening of the function increases not only due to the inclusion of structural and functional units of organs that did not work before (for example, nephrons), but also as a result of an increase in the intensity of their work, which in turn causes the activation of plastic processes and an increase in the mass of the organ (hypertrophy) to a level where the load for each functioning unit does not exceed the normal.
The inclusion of compensatory mechanisms, as well as the termination of their activity, depends primarily on nervous system. P. K. Anokhin formulated the concept of functional systems that specifically compensate for a functional defect caused by damage. These functional systems are formed and work according to certain principles: 1. Signaling about the violation that has occurred, leading to the activation of the corresponding compensatory mechanisms. 2. Progressive mobilization of spare compensatory mechanisms. 3. Reverse afferentation about successive stages of restoration of disturbed functions. 4. Formation in the central nervous system of such a combination of excitations that determines the successful restoration of functions in the peripheral organ. 5. Assessment of the adequacy and strength of the final compensation in dynamics. 6. The collapse of the system as unnecessary.
The sequence of compensation stages can be traced on the example of lameness in case of damage to one leg: 1) signaling of imbalance from the vestibulocochlear organ; 2) restructuring the work of motor centers and muscle groups in order to maintain balance and the possibility of movement; 3) caused by a stable anatomical defect, constant combinations of afferents entering the higher departments central nervous system, and the formation of temporary connections that provide optimal compensation, i.e., the ability to walk with minimal lameness.
relapse- a new manifestation of the disease after an apparent or incomplete cessation of it, for example, the resumption of attacks of malaria after a more or less long interval. Observe relapses of pneumonia, colitis, etc.
Transition to the chronic form means that the disease proceeds slowly, with long periods of remission (months and even years). This course of the disease is determined by the virulence of the pathogen and mainly by the reactivity of the organism. Yes, in old age many diseases become chronic (chronic pneumonia, chronic colitis).
Terminal States- the gradual cessation of life even with seemingly instantaneous death. This means that death is a process, and several stages (terminal states) can be distinguished in this process: pre-agony, agony, clinical and biological death.
preagony can be of different duration (hours, days). During this period, there is shortness of breath, a decrease in blood pressure (up to 7.8 kPa - 60 mm Hg and below), tachycardia. A person has a blackout of consciousness. Gradually pre-agony turns into agony.
Agony(from the Greek agon - struggle) is characterized by a gradual shutdown of all body functions and at the same time by extreme tension of protective mechanisms that are already losing their expediency (convulsions, terminal respiration). Duration of agony - 2 - 4 minutes, sometimes more.
clinical death they call such a state when all visible signs of life have already disappeared (breathing and heart function have stopped, but the metabolism, although minimal, is still ongoing). At this stage, life can be restored. That is why the stage clinical death attracts special attention of clinicians and experimenters.
biological death characterized by irreversible changes in the body.
Experiments on animals, primarily on dogs, made it possible to study in detail the functional, biochemical, and morphological changes at all stages of dying.
Dying is the disintegration of the integrity of the organism. It ceases to be a self-regulating system. At the same time, systems that unite the body into a single whole are first destroyed, primarily the nervous system. At the same time, the lower levels of regulation are preserved to some extent. In turn, there is a certain sequence of dying of various parts of the nervous system. The cerebral cortex is most sensitive to hypoxia. With asphyxia or acute blood loss, neuronal activation is first observed. In this regard, there is motor excitation, increased respiration and heart rate, increased blood pressure. Then inhibition occurs in the cortex, which has a protective value, since for some time it can save cells from death. With further dying, the process of excitation, and then inhibition and exhaustion, extends lower, to the brain stem and reticular pharmacy. These phylogenetically older parts of the brain are the most resistant to oxygen starvation (the centers of the medulla oblongata can tolerate hypoxia for 40 min).
In the same sequence, changes occur in other organs and systems. With fatal blood loss, for example, during the first minute, breathing sharply deepens and quickens. Then its rhythm is disturbed, the breaths become either very deep or superficial. Finally, the excitation of the respiratory center reaches its maximum, which is manifested by especially deep breathing, which has a pronounced inspiratory character. After that, breathing weakens or even stops. This terminal pause lasts 30.-60 s. Then breathing resumes temporarily, acquiring the character of rare, at first deep, and then more and more superficial breaths. Together with the respiratory center, the vasomotor center is activated. Vascular tone increases, heart contractions increase, but soon stop and vascular tone decreases.
It is important to note that after the cessation of the work of the heart, the system that generates excitation continues to function for quite a long time. On the ECG, biocurrents are noted within 30 - 60 minutes after the disappearance of the pulse.
In the process of dying, characteristic changes in metabolism occur, mainly due to the ever-deepening oxygen starvation. Oxidative metabolic pathways are blocked and the body obtains energy from glycolysis. The inclusion of this ancient type of metabolism has a compensatory value, but its low efficiency inevitably leads to decompensation, aggravated by acidosis. Clinical death occurs. Breathing stops, blood circulation stops, reflexes disappear, but the metabolism, although at a very low level, still continues. This is enough to maintain the "minimal life" of nerve cells. This explains the reversibility of the process of clinical death, i.e., in this period, revival is possible.
A very important issue is the time frame during which resuscitation is possible and appropriate. After all, revival is justified only in the case of restoration of mental activity. V. A. Negovsky and other researchers argue that positive results can be achieved no later than 5-6 minutes after the onset of clinical death. If the process of dying continues for a long time, leading to the depletion of the reserves of creatine phosphate and ATP, then the period of clinical death is even shorter. On the contrary, with hypothermia, revival is possible even an hour after the onset of clinical death. In the laboratory of N. N. Sirotinin, it was shown that it is possible to revive a dog 20 minutes after death as a result of bleeding, followed by a complete restoration of mental activity. However, it should be borne in mind that hypoxia causes greater changes in the human brain than in the brain of animals.
Resuscitation, or revitalization, of the body includes a number of activities that are primarily aimed at restoring blood circulation and respiration: heart massage, artificial ventilation of the lungs, defibrillation of the heart. The last event requires the availability of appropriate equipment and can be carried out under special conditions.
We reviewed five theories of the pathogenesis of the disease and criticized all of them.
"Whom to love, who to trust?" - Asked Pushkin. And he answered: "Love thyself, my venerable reader." There is no generally accepted scheme for the pathogenesis of the disease. Our working synthetic circuit looks like this. The etiological factor in the presence of conducive conditions, interacting with the body, causes damage, irritation and changes in metabolism. This changes the functional state of regulatory systems and leads to the deployment of adaptive and pathological reactions. As a result, pathological processes are formed that change the functional state of organs and systems. The changes that arise in connection with the reverse afferentation determine the formation of a new qualitatively unique regulation of functions.
Thus, a disease is a stable change in the functions of organs and systems, combined with a qualitatively unique integration of them. This scheme has a number of features. First of all, it proceeds from the fact that a disease is always a combination of damage and adaptation, local and general, structural and functional changes. The scheme indicates the "atoms" (damage, adaptive and pathological reactions, changes in metabolism) and "molecules" (pathological processes) of the disease. The scheme reflects the role of regulatory systems in the development of the pathological process. This issue is worth discussing in more detail.
Among the inhabitants there is an idea that "all diseases are from nerves." The already discussed thesis of A.D. Speransky: "The nervous system organizes the pathological process." In fact, this idea is supported both by the concept of psychosomatic medicine and by the views of supporters of cortico-visceral pathology. In reality, however (and this follows from the scheme), the role of regulatory systems in the development of a pathological process can be twofold: their main, main role is to prevent or mitigate the development of a pathological process (adaptive reactions play this role), but if regulatory systems with do not resist this mission, they can act as the organizer of the pathological process (this role is performed by pathological reactions). Hasn't the nervous system ruined your life? It used to. Of course it did. So Speransky was right? Yes, but... but only partly. He did not emphasize the main thing - the sanogenic role of regulatory systems. After all, health is a necessity, and illness is just an accident. So, long live our regulatory systems? Certainly! But they inspire many of our diseases. What can you do: absolutely positive phenomena do not exist. Dialectics!
Scheme highlights quality of the disease. It consists in the presence of damage, pathological reactions and qualitative originality of the integration of functions. The latter needs an explanation. El Registan has these verses:
You can’t put everything on the shelves,
You will not pour everything into flasks,
Not everything can be divided and multiplied
And the exact formula will kill you.
Cut, cut, do not regret
My scholarly friends
In a flute sawn to pieces
Look for the longing formula.
And prove impartially
Spread love on glass
What do the happy and the unhappy
One chemical composition.
It is by no means easy to reveal the qualitative originality of phenomena. Indeed, does the body temperature of 36.6 degrees (norm) qualitatively differ from the temperature of 37.6 degrees. (when fever develops)? Is BP 120/80 mm Hg. Art. (norm) is qualitatively different from blood pressure 220/110 mm Hg. (for hypertension) Isn't it true that the differences here are purely quantitative? Yes, quantitative, if we compare only numbers. But if we analyze the features of regulation (thermoregulation, regulation of blood pressure), then it must be recognized that in conditions of pathology there are qualitative differences in the regulation of functions. Try to cool the feverish person. It will increase heat production (will develop muscle tremor), heat transfer will decrease (spasm of skin vessels will develop), and body temperature will be kept at a high “feverish” level. Does this mean that the body needs this level of temperature? So the thermoregulatory set point (that toggle switch of the organism's thermostat) has been switched to a different level of functioning? Try lowering blood pressure in a hypertensive patient. After a while, it will return to high level. This means that the regulation of blood pressure in the patient is shifted to this new level? This is the qualitatively unique integration of functions in illness.
At one time, I.P. Pavlov pointed out that during illness - and this is the main thing - there is a violation of the relationship between the body and the environment. IV Davydovsky criticized this thesis. Indeed, most of the heads of departments at our university are middle-aged people; most of them have symptoms of atherosclerosis, some have elevated blood pressure. Is it possible to conclude that they have broken relationships with the external environment? After all, with the performance of their difficult duties, they are quite coping. However the adaptive capabilities of the body during illness - and this is probably the main thing - of course, are limited. It follows from the diagram that in case of illness, adaptive reactions are necessarily included, and this requires a certain tension, mobilization and use of energy resources.
All these considerations lead us to definition of norm, health and disease. Immediately make a reservation: there is no single generally accepted definition of these states. Suffice it to say that there are about 200 definitions of the concept of norm. We will not touch on the history of this issue and quote the classics. We restrict ourselves to modern definitions.
It seems to us that the definition of the norm formulated by V.P. Petlenko is successful: "The norm is the interval of optimal functioning of a living system."
World Health Organization (WHO) experts have given a very controversial definition of health: “Health is a state of complete physical, mental and social well-being, and not just the absence of disease and physical defects.” Based on this definition, E.I. Chazov proposed his own formulation; "Health is the psycho-physiological optimum for meeting material and spiritual needs." It seems to us that these are definitions of happiness, not health. If you follow the logic of these definitions, then you should recognize as unhealthy all ... the unemployed, the poor, the divorced, and so on. A more rational definition is given by I.A. Gundarov and V.A. Polessky: “Health is such a state of the body and such a form of life activity that provides an acceptable life span, its necessary quality (physical, mental, social) and sufficient social capacity. Pediatricians believe that this definition should be supplemented with "a set of properties of the child's body, ... guaranteeing its subsequent optimal development, disclosure of all positive properties personality, talent and giftedness. However, it is impossible not to notice that life expectancy and the disclosure of positive personality traits largely depend on the hereditary program and the characteristics of upbringing, and “quality of life” is a very amorphous concept. With all this in mind, we use the following definition as a working definition: "Health is the sustainable maintenance of homeostasis."
Our Ministry of Health has always been focused on the fight, and the Academy medical sciences was primarily concerned with the study of disease. What organization is engaged in studying, protecting and increasing the health of the population in our country? Strange as it may seem, we don't have such an organization! That's why Professor I.I. Brekhman proposed to create new science- “Valeology” - the science of health. The name comes from the Latin word "Vale", which means "be healthy." Remember, Pushkin:
... Talk about Juvenal,
Put "Vale" at the end of the letter.
II Brekhman published two monographs devoted to this science. In St. Petersburg, Professor V.P. Petlenko created the first department of valeology. In Khabarovsk, courses of lectures on this discipline are read at some institutes. Health is a concern for everyone. It is no coincidence that V.A. Sukhomlinsky believed that the first lesson in any educational institution should be a health lesson. For a philosophical consideration of health, it is important to understand that it reflects a necessity arising from the essence of phenomena, and illness is an accident that does not have a universal character. Paradoxical as it may seem, but medicine is predominantly concerned with random phenomena: the lion's share of capital investments goes to the treatment of the sick and crumbs to the health of the healthy.
The Soviet Union has always declared preventive direction our medicine. To protect the health of the population, the method of general medical examination was widely used. However, clinical examination practice has shown that this method has many significant drawbacks. It has long been known that an idea is necessarily discredited if it is separated from interest. Clinical examination was actually carried out by force. Activity was shown not by the population, but by medical workers. The lack of methods for measuring health has led to the fact that medical examinations were focused not on the prognosis of health, but on the diagnosis of the disease. As a result, practical medicine in our country is not responsible for the level of public health. After all, health is judged only by the absence of disease. General "barracks" (the same for everyone) recommendations to follow healthy lifestyle of life prescribe equality of conduct, but cannot ensure equality of health.
Of course, measuring health is probably no easier than measuring beauty, love, and happiness. However, we still have beauty contests! Academicians N.M. Amosov and V.P. Kaznacheev have long insisted on measuring the amount of health. R.M. Baevsky proposes to measure the degree of tension of regulatory systems for this purpose, G.L. Apanasenko - to register in points the body's ability to generate energy. I.A. Gundarov and V.A. Polessky propose to create a valeological service, which would quantify the health of each person on the basis of simple studies and personal data and ensure its correction and strengthening.
No less difficult is the definition of the disease. Invariably popular is the deep, figurative, but non-medical definition of K. Marx, who in one of his letters noted that the disease is “a power life in its freedom”. Disease is often defined as a negation of health. So, in the new textbook of pathophysiology, published by V.V. Ivanov in 1994, the disease is considered as a violation of physical and mental health, as well as human social relations. The trouble is that, as already mentioned, there is no generally accepted definition of health yet.
According to our definition of health, we regard illness as persistent violation homeostasis. Students like this definition because of its brevity. However, it is certainly not complete. In a detailed definition, in our opinion, it is necessary to note the qualitative originality of the disease.
It is very important to emphasize that disease is always a combination of injury and adaptation. Why is it important? The fact is that the idea of a disease as a process that harms the body is very common. I have repeatedly asked different artists to draw an image of the disease in our classroom. They all drew something terrible. It's not just the general public that thinks so. Once, in a class with doctors, I asked: “Is illness good or bad?” The answer was unanimous: “What good is that?” Of course it's bad! Therefore, we fight diseases all our lives.” I spoke about this episode at a philosophical seminar for teachers of our institute. On the faces of the participants of the seminar - professors, associate professors and assistants - bewilderment was depicted. After a pause, one of the professors said, “What's so strange about that? Doctors are well oriented!” But academician I.V. Davydovsky believed that all nosology is adaptation through illness, that there are no pathological reactions and processes at all, that only adaptive reactions have formed in the process of evolution (remember: “Nature does not have bad weather”).
Students like to ask: "What's the right way?" But I don't know... None of us is the bearer of the truth in the final instance. In one of the classrooms, we hung out a banner with an aphorism: “To fog up, to ferment!” (This is from the program of the famous pop actor Arkady Raikin) Unfortunately, the chairman of the commission that checked our institute did not like this aphorism, and the banner had to be removed. I am impressed by the point of view of Ivan Petrovich Pavlov, who believed that a disease is always a combination of damage and adaptation, and the measure of the doctor’s talent determines whether he will be able to find out the damage (in order to stop it) and recognize the adaptation (in order to strengthen it).
After Selye's work, apparently, information about the development of the disease along with specific and nonspecific changes should be included in the definition. And, of course, one cannot do without reflecting the biological and social consequences of the disease.
All this should be remembered when defining the essence of the disease. Definitions don't really matter. Depth of understanding is important. However, since for the purposes of studying it is convenient for students to have a concise formulation that, in some approximation, reflects the essence of the process, such a definition of the disease can be used as a working one. Illness is caused by the action of external or internal causes a qualitatively unique process characterized by a combination of damage and adaptation, specific and nonspecific changes in homeostasis, and limitation of the organism's adaptive capabilities.
Along with health and illness, there is also the so-called "third state" - health, no illness, "pre-nosological state", "pre-illness". This state was distinguished by Galen and Avicenna. In fact, how to qualify the condition of a woman in the pre - and postpartum period, during the days of menstruation and during menopause? How to call the state of the body immediately after birth, or during puberty, or in old age? You can hardly call it health. But it's not a disease either. "Third state" we define as a state of unstable homeostasis associated with congenital or acquired weakness of adaptive mechanisms or with their constant voltage. I.I. Brekhman believed that the vast majority of people are in the third state, and this state can last for years, decades, and sometimes for a lifetime. Reducing the number of people in this state is the most important task of medical and biological science.
PHASES OF DISEASE DEVELOPMENT
The disease develops in phases. The period between the onset of exposure to a disease-causing agent and the appearance of symptoms of the disease is called latent, or latent. In infectious diseases, it is called incubation. The period from the first appearance of signs of an incipient disease to the full development of its symptoms is called prodromal. It is followed by periods of the height of the disease and outcomes (recovery, transition to a pathological state or death).
We studied the phases of development of an acute general pathological process on the model of oxygen starvation. It is easy to show experimentally that an acute general pathological process develops in phases. If an animal is placed in a hermetically sealed vessel with a carbon dioxide absorber, then oxygen starvation will gradually begin to develop in it. The first phase of the process is characterized by the inclusion of adaptive mechanisms: breathing quickens. Due to this, the oxygen content in the blood does not change for some time. This is the phase of compensation, the phase of pre-illness, the phase of maintaining homeostasis. In the experiment, the compensation phase can be measured by the time from the onset of the stimulus to the start of a change in homeostasis.
Further, the oxygen content in the hermetically closed space progressively decreases (after all, the animal absorbs oxygen during respiration). The body is no longer able to maintain the desired concentration of oxygen in the blood. Oxygen homeostasis is disturbed. The decompensation phase develops. Experience reveals two qualitatively different periods in it. In the first period, adaptive mechanisms work. In our experience, shortness of breath increases to a maximum. However, quantitatively adaptive mechanisms are insufficient. Violation of homeostasis is gradually but steadily deepening. This period can be called a period of relative insufficiency of adaptive mechanisms, a period of quantitative changes. However, the strength of the stimulus continues to grow. Adaptive mechanisms have some limit of performance, and they do not withstand. There is a breakdown. In our experience, breathing begins to progressively decrease. At the same time, the rate of decrease in the oxygen content in the blood (i.e., the rate of homeostasis disturbance) catastrophically increases until the death of the animal. This is the second period of the decompensation phase - the period of disruption of adaptive reactions - the period of disruption of adaptive reactions (decrease in breathing instead of quickening when oxygen starvation is a pathological reaction), a period of qualitative changes. The period of quantitative changes is measured by the time from the beginning of homeostasis changes to the disruption of the main adaptive mechanisms (in our experience, from the beginning of a decrease in the oxygen content in the blood to the change from an increase in breathing to a decrease in it). The period of qualitative changes can be measured by the time from the moment of disruption of the main adaptive mechanisms to the death of the animal (in our experience, from the moment of change from quickening of breathing to its slowing down to the moment of stopping breathing).
So, an acute general pathological process develops through a phase of compensation and a phase of decompensation. The latter is divided into two periods - the period of quantitative and the period of qualitative changes ...
The deepening of the pathological process may be due to the predominance of deviating factors over the adaptive capabilities of the body. This can be in three cases: in the case when the deflecting factors are too strong; in the case when adaptive mechanisms are weak; in the case when the self-regulation processes are violated in the body. The latter requires an explanation.
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ACUTE rheumatic fever
Acute rheumatic fever is a post-infectious complication of tonsillitis (tonsillitis) or pharyngitis caused by group A β-hemolytic streptococcus, manifested as systemic inflammatory disease connective tissue with a primary lesion of the CCC (carditis), joints (migratory polyarthritis), brain (chorea) and skin (erythema annulare, rheumatic nodules).
Acute rheumatic fever develops in susceptible individuals, mainly young age(7-15 years), and is associated with an autoimmune response of the body due to cross-reactivity between Ag of streptococcus and Ag of affected human tissues (the phenomenon of molecular mimicry).
Chronic rheumatic heart disease is a disease characterized by damage to the heart valves in the form of marginal fibrosis of the valvular leaflets of inflammatory origin or heart disease (failure and / or stenosis) formed after acute rheumatic fever.
The incidence of acute rheumatic fever in Russia is 2.7 cases per 100,000 population, chronic rheumatic diseases heart - 9.7 cases per 100,000 population, including rheumatic heart disease - 6.7 per 100,000 population. The prevalence of chronic rheumatic heart disease is 28 cases per 100,000 children and 226 cases per 100,000 adults. Mostly people aged 7-15 years get sick. Sexual dimorphism is not clearly visible.
ETIOLOGY
HEMOLYTIC STREPTOCOCCUS
Acute rheumatic fever develops 2-4 weeks after suffering a sore throat or pharyngitis caused by highly contagious "rheumatogenic" strains of group A hemolytic streptococcus (serotypes M3, M5, M18, M24). M-protein (a specific protein that is part of the cell wall - β hemolytic streptococcus group A and suppresses its phagocytosis) contains antigenic determinants that are similar to the components of the heart muscle, brain and synovial membranes.
GENETIC FACTORS
The role of genetic factors is evidenced by the higher prevalence of acute rheumatic fever and chronic rheumatic heart disease (including rheumatic heart disease) in individual families. In 75-100% of patients and only in 15% healthy people on B-lymphocytes there is a specific alloantigen 883 (D8/17), which is detected using special monoclonal antibodies.
PATHOGENESIS AND PATHOMORPHOLOGY
Several mechanisms are involved in the development of acute rheumatic fever. A certain role can be played by direct toxic damage components of the myocardium with cardiotropic enzymes of β - hemolytic streptococcus group A. However, the main importance is attached to the development of a cellular and humoral immune response to various Ag streptococci. Synthesized antistreptococcal antibodies cross-react with myocardial Ag (phenomenon of molecular mimicry), as well as with cytoplasmic Ag nervous tissue, localized in the subthalamic and caudal zones of the brain (mainly in the striatum). In addition, the M-protein has the properties of a superantigen - it causes a strong activation of T-lymphocytes and B-lymphocytes without its preliminary processing by Ag-presenting cells and interaction with molecules of the major histocompatibility complex class II.
STAGES OF THE PATHOLOGICAL PROCESS
In acute rheumatic fever, four stages of the pathological process in the connective tissue are distinguished.
Stage of mucoid swelling.
Stage of fibrinoid necrosis (irreversible phase of connective tissue disorganization).
The stage of proliferative reactions, in which the formation of Ashoff-Talalaev granulomas occurs as a result of necrosis of the heart tissue and proliferation of connective tissue cells.
stage of sclerosis.
Rheumatic granuloma consists of large, irregular shape basophilic cells, giant multinucleated cells of myocytic origin with eosinophilic cytoplasm, as well as lymphoid, plasma cells. Granulomas are usually located in the myocardium, endocardium, perivascular connective tissue of the heart. Currently, granulomas are less common. With chorea, the cells of the striatum change. Skin lesions and subcutaneous tissue due to vasculitis and focal inflammatory infiltration.
CLASSIFICATION
In our country, the classification and nomenclature is generally accepted. rheumatism, developed by A.I. Nesterov and approved at the symposium of the antirheumatic committee. This classification and nomenclature should be used when formulating a diagnosis of rheumatism in children, adolescents and adults.
| Table 2. Working classification and nomenclature of rheumatism | |||||
| Illness phase | Clinical and anatomical characteristics of lesions | The nature of the flow | Circulatory status | ||
| hearts | other systems and organs | ||||
| Active | Rheumocarditis, primary without valvular disease | Polyarthritis, serositis (pleurisy, peritonitis, abdominal syndrome) | Acute, subacute | H0 | |
| Activity I, II, III degree | Recurrent rheumatic heart disease with valvular disease (what kind) | Chorea, encephalitis, meningoencephalitis, cerebral vasculitis, neuropsychiatric disorders | Protracted, continuously recurrent, latent | H I | |
| Rheumatism without obvious cardiac changes | Vasculitis, nephritis, hepatitis, pneumonia, skin lesions, iritis, iridocyclitis, thyroiditis | H IIA H IIB | |||
| Inactive | 1. Rheumatic myocardiosclerosis 2. Heart disease (what) | Consequences and residual effects past non-cardiac lesions | H III |
CLINICAL PICTURE
The nature of the onset of acute rheumatic fever is closely related to the age of the patients. In more than half of the children, the disease occurs 2-3 weeks after a sore throat with a sudden increase in body temperature, the appearance of asymmetric migrating pains in large joints (most often in the knees) and signs of carditis (chest pain, shortness of breath, palpitations, etc.). In some patients, a monosymptomatic course is observed with a predominance of signs of arthritis or carditis (or very rarely, chorea). Just as acutely, by the type of "outbreak", acute rheumatic fever develops in recruit soldiers who have suffered a sore throat. For teens and young adults after subsiding clinical manifestations angina is more typical of a gradual onset with subfebrile body temperature, arthralgia in large joints, or only moderate signs of carditis. A repeated attack of acute rheumatic fever is also associated with a past infection of the pharynx of streptococcal etiology and is manifested mainly by the development of carditis.
ARTHRITIS
Arthritis (or arthralgia) of several large joints is one of the leading symptoms of the disease in 60-100% of patients with the first attack of acute rheumatic fever. Joint pain is often so pronounced that it leads to a significant limitation of their mobility. Simultaneously with pain, swelling of the joints is noted due to synovitis and damage to the periarticular tissues, sometimes redness skin over the joints. The knee, ankle, wrist and elbow joints are most commonly affected. The predominant form of the lesion in modern conditions- transient oligoarthritis and rarely monoarthritis. Characteristics rheumatoid arthritis - migratory in nature (signs of damage to some joints almost completely disappear within 1-5 days and are replaced by the same pronounced defeat other joints) and rapid complete regression under the influence of modern anti-inflammatory therapy.
CARDITIS
Carditis is a manifestation of acute rheumatic fever (observed in 90-95% of cases), which determines the severity of the course and outcome of the disease. The underlying component of carditis is valvulitis (mainly of the mitral valve, less often of the aortic valve), which can be combined with damage to the myocardium and pericardium. Symptoms of rheumatic valvulitis:
Blowing systolic murmur of apical localization associated with tone I (with mitral regurgitation);
Intermittent low-frequency mesodiastolic murmur in the auscultation area of the mitral valve;
High-frequency decreasing proto-diastolic murmur heard along the left edge of the sternum (with aortic regurgitation).
The myocardium and pericardium may be involved in the pathological process with the development of tachycardia, expansion of the boundaries of cardiac dullness, muffled heart sounds, pericardial friction noise, conduction disturbances, etc. However, an isolated heart lesion of the type of myopericarditis in the absence of valvulitis is not characteristic of acute rheumatic fever, and in these cases, an differential diagnosis with carditis of a different etiology (see below).
Against the background of pronounced arthritis or chorea minor clinical symptoms carditis in acute rheumatic fever may be mild. In this regard, the diagnostic significance of echocardiography using the Doppler mode increases.
The most important feature carditis during the first attack of acute rheumatic fever - a clear positive dynamics of its clinical manifestations under the influence of active antirheumatic therapy. In the vast majority of cases, treatment results in normalization of heart rate, restoration of sonority of tones, a decrease in the intensity of systolic and diastolic murmurs, a reduction in the boundaries of the heart, and the disappearance of symptoms of circulatory failure.
The social significance of acute rheumatic fever is determined by acquired rheumatic heart disease, which, as it progresses, leads to permanent disability and a reduction in life expectancy. The incidence of rheumatic heart disease after the first attack of acute rheumatic fever in children is 20-25%. Isolated heart defects predominate, more often mitral insufficiency. Less often, aortic valve insufficiency, mitral stenosis and combined mitral-aortic heart disease are formed (for more details, see Chapter 8 "Acquired heart defects"). Approximately 7-10% of children after suffering carditis develop mitral valve prolapse.
Among adolescents who have suffered the first attack of acute rheumatic fever, heart defects are diagnosed in a third of cases. In adult patients, this figure is 39-45%, and the maximum incidence of rheumatic heart disease (more than 75%) is observed during the first three years from the onset of the disease. In patients who had the first attack of acute rheumatic fever at the age of 23 years and older, concomitant and combined rheumatic heart defects are formed in 90% of cases.
CHOREA
Rheumatic chorea (small chorea, Sydenham's chorea) is a typical manifestation of acute rheumatic fever associated with the involvement of various brain structures (striatum, subthalamic nuclei and cerebellum) in the pathological process. It is diagnosed in 6-30% of cases, mainly in children, less often in adolescents 1-2 months after suffering an acute streptococcal infection. Girls and girls are more often affected. The clinical picture of chorea minor includes various combinations the following syndromes:
Choreic hyperkinesis, i.e. involuntary twitching of the limbs and mimic muscles, accompanied by a violation of handwriting, slurred speech, awkward movements;
Muscular hypotension (up to muscle flabbiness with imitation of paralysis);
Disorders of statics and coordination (inability to perform coordination tests, such as finger-nose);
Vascular dystonia;
Psycho-emotional disorders (mood instability, irritability, tearfulness, etc.). Characterized by the complete disappearance of symptoms in a dream.
Chorea minor, as a rule, is combined with other clinical manifestations of acute rheumatic fever (carditis, polyarthritis), but in 5-7% of patients it may be the only sign of the disease. In these situations, i.e. in the absence of other criteria for acute rheumatic fever, the diagnosis of rheumatic chorea is competent only after the exclusion of other causes of damage to the nervous system.
erythema annulare
Ring-shaped (annular) erythema is observed in 4-17% of patients at the height of acute rheumatic fever. It is characterized by pale pink ring-shaped rashes ranging in diameter from a few millimeters to 5-10 cm, predominantly localized on the trunk and proximal extremities (but not on the face). It has a transient migratory character, does not rise above the level of the skin, is not accompanied by itching or induration, turns pale when pressed, quickly regresses without residual effects.
Similar information.
Health is the most important value of life. Only thanks to the complete physical and mental well-being of people can they achieve their goals, be truly happy, and experience the joy of communicating with the world. Unfortunately, health is not always the norm. It worsens due to pathological processes occurring in the body.
Explanation of the term
Pathological process- naturally occurring in human body subsequence various reactions, manifested in the form of functional, metabolic and morphological disorders. They appear in response to the damaging effect of a pathogenic factor.
Pathological processes are divided into 2 types: local (they are characterized by direct contact of the pathogenic factor with tissues) and generalized (they occur in the human body, regardless of the zone of action of pathogenic factors). The latter progress in accordance with 3 phases:
Characteristics of pathological processes
The reactions of the body that occur in response to the influence of any factors that cause a violation of the normal course of life processes are characterized by certain characteristics. These include:
A set of processes or a specific pathological process is what underlies any disease. That is why, in relation to reactions, such a characteristic as universality is used. Autochthonousness is also inherent in pathological processes. This term indicates the ability of the pathological process to develop regardless of whether the causal factor. It also uses such a characteristic as stereotyping. It means that certain features are inherent in the pathological process. They do not change due to the reasons that caused the process, or the place of its localization.
The difference between a pathological process and a disease
Many consider the terms "disease" and "pathological process" to be synonymous. This is not true. Here are the main differences between the concepts:
Stages inherent in the pathological process
A person is constantly affected by various pathogenic factors. external environment(biological, physical, etc.). Some of them are neutralized by the body's defenses. Those factors that cannot be overcome cause a pathological process.
The reactions of the body are characterized by progression, so the following stages of the pathological process can be conditionally distinguished:
First stage
The occurrence of any reaction of the body is explained by the influence of a specific stimulus. The appearance of suspicious symptoms in a person depends on the following factors:
A pathological process is something that can begin in the human body due to the ingress of pathogens or mechanical action of great force. However, the influence of a group of factors is most often observed.
Second stage
Each pathological process has its own specifics in progression. Despite this, one can distinguish general principles, along which development takes place:
Third stage
As a pathological process develops, effective sanogenetic (protective) mechanisms can intervene. In this case, the result is, as a rule, recovery, restoration of the initial state. If the body's defenses do not cope, then as a result of the pathological process, a disease develops. Each ailment lasts for a certain time. Acute diseases last about 4 days, acute - from 5 to 14 days, subacute - from 15 to 40 days. After the disease, either recovery occurs or the transition to a chronic form and the development of complications, or death.
What can be attributed to pathological processes
Pathological processes in the body can be as follows:
Most a prime example is pathological inflammatory process. With it, a protective-adaptive reaction to the elimination of the pathogenic factor begins to act in the human body. Inflammation provokes a change in normal blood circulation, an increase in vascular permeability. There are such clinical symptoms, as local fever, redness, pain.
Such a pathological process as hypoxia means oxygen deficiency. She is inherent various states and diseases. For example, at the end of any fatal illness, regardless of the causes that caused it, acute oxygen deficiency occurs. Dying is always accompanied by total hypoxia, which provokes irreversible changes in the human body. Fever is often observed. This is a pathological process, which is characterized by a temporary increase in body temperature. It also exhibits other negative phenomena inherent in infectious pathologies(eg, hot flashes). Another example of a pathological process is a tumor. This is a neoplasm that appears with the growth of tissues with atypical cells. Tumors are polyetiological. This means that they arise due to the influence of various factors of a physical, chemical, biological nature.
In conclusion, it is worth noting that diseases, the pathological process are different concepts, but very important. Each person should know what reactions can occur in his body due to exposure to various stimuli, what can be the result of all the changes that occur.
Semiotics of damage to the nervous system in children
1.3 Phases of the development of the pathological process in case of damage to the nervous system in children of the 1st year of life
First phase -- acute period disease, lasting up to 1 month of life, directly associated with hypoxia and circulatory disorders, can clinically manifest itself as a syndrome of depression or a syndrome of CNS excitation.
The second phase of the pathological process extends to the 2nd-3rd months of life, there is a decrease in the severity neurological disorders: general condition improves, increases physical activity, normalization occurs muscle tone, reflexes. Improved electroencephalographic parameters. This is explained by the fact that the affected brain does not lose the ability to recover, but the duration of the second phase is short and soon (by the 3rd month of life) an increase in spastic phenomena may occur. The phase of "unjustified hopes for a full recovery" ends (it can be called the phase of false normalization).
The third phase - the phase of spastic phenomena (3-6 months of life) is characterized by the predominance of muscle hypertension (i.e., an increase in muscle tone). The child throws back his head, bends his arms at the elbows and brings them to the chest, crosses his legs and puts them on his toes when supported, tremor is pronounced, often convulsive states and others. The change in the clinical manifestations of the disease may be due to the fact that in this period there is a process degeneration (the number of dystophically altered neurons increases). At the same time, in many children with hypoxic lesions of the nervous system, the emerging progress in the second phase of the disease is fixed, which is found in the form of a decrease in neurological disorders.
The fourth phase (7-9 months of life) is characterized by the division of children with perinatal lesions of the nervous system into two groups: children with obvious neuropsychiatric disorders up to severe forms children with cerebral palsy (20%) and children with normalization of previously observed changes in the nervous system (80%). This phase can be conditionally called the phase of the end of the disease.
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