From Big Medical Encyclopedia

BREAST [thorax, pectus (PNA, JNA, BNA)] — an upper part of a trunk. G.'s border from above passes on the upper edge of the handle of a breast, clavicles and further across the conditional line going from acromial and clavicular joints to a top of an acantha of the VII cervical vertebra; the line drawn from a xiphoidal shoot on costal arches to the X edge, to the front ends XI and XII edges and further on bottom edge of the XII edges to an acantha of the XII chest vertebra is considered the lower bound of G.


On PNA the breast is divided into the following areas: subclavial (regio infraclavicularis), mammary gland (regio mammalis) and axillary (regio axillaris).

Fig. 1. Areas of a breast (and — in front; — behind): 1 — regio thoracis anterior superior (s. regio mammalis); 2 — regio mediana thoracis anterior (s. regio sternalis); 3 — regio thoracis anterior inferior (s. regio inframammalis); 4 — regio thoracis posterior inferior (s. regio infrascapularis); 5 — regio mediana thoracis posterior (s. regio vertebralis); <S — regio thoracis posterior superior (s. regio scapularis).
Fig. 2. Extreme shapes of a breast: and — wide and short; — narrow and long (across Margorin).

In the USSR other anatomotopografichesky division of G. (fig. 1) is accepted: front median area, or area of a breast (regio mediana thoracis ant., s. regio sternalis); lobby upper, or area of a mammary gland (regio thoracis ant. sup., s. regio mammalis); front lower, or subchest, area (regio thoracis ant. inf., s. regio inframammalis); back median, or vertebral, area (regio mediana thoracis post., s. regio vertebralis); back upper, or scapular, area (regio thoracis post, sup., s. regio scapularis); back lower, or infrascapular, area (regio thoracis post, inf., s. regio infrascapularis). In the topografoanatomichesky relation in G. allocate a chest wall — set of a bone thorax and soft tissues (see. Thorax ) and chest cavity (see). Through an upper aperture of G. (apertura thoracis sup.) enter a chest cavity and there are it bodies of a neck and a mediastinum. From below the chest cavity is closed diaphragm (see). Extent of a chest cavity does not match borders of. At the top of a kupola of a pleura and a top of lungs G. to the area of a neck go beyond, below the chest wall covers the bodies located in a cavity of a stomach (a liver, a spleen, a part of kidneys, etc.) thanks to what developing of thoracoabdominal wounds (is possible see. Torakoabdominalny damages ). The form G. reminds the truncated cone flattened in the perednezadny direction with the basis turned up; it is individually various that is connected with a shape of a thorax and extent of development of muscles of a shoulder girdle. Extreme forms G. it is considered to be wide and short, narrow and long (fig. 2). The first is characterized by a wide and short thorax, stupid under a sternal corner, the position of edges, narrow intercostal spaces, a wide breast coming to horizontal. At narrow long G. an acute substernal angle, intercostal spaces wide, a breast narrow. Sexual and age distinctions of a form G. are noted: at G. women more often narrow and long, at children — cylindrical. At a row patol, processes the form G. can have idiosyncrasies: funneled — at inborn defects of G., «chicken» — at a kyphosis, barrel-shaped — at the expressed emphysema of lungs, etc.

Within G. a number of the reference points important at projection of bodies on a chest wall and localizations patol, the centers and wounds is defined. Among them jugular cutting, the handle, a corner (corresponds to the II edge) and a midsternum, its xiphoidal shoot, clavicles, edges (except for I) and costal arches are well palpated; behind — acanthas of vertebrae, shovels with their edges, shoots, lower and medial and upper corners and a scapular awn; the chest nipple corresponding at men to bottom edge of the IV edge or the IV mezhreberye, and at women — depending on the size of mammary glands is visible. At men at survey big pectoral muscles, teeth of front gear muscles, the outer edge of a trapezoid muscle, subclavial poles, deltoid and chest furrows can be noticeable. For specification of a projection of the bodies which are in a chest cavity on G.'s surface use vertical conditional lines parallel each other: front and back midlines (lineae medianae ant. et post.), which respectively pass through the middle of a breast and, on acanthas of vertebrae; sternal (linea sternalis) — on edge of a breast; median and clavicular (linea mediocla vicularis) — through the middle of a clavicle; okologrudny (linea parasternalis) — in the middle of distance between sternal and median and clavicular lines; front, back and average axillary lines (lineae axillares ant., post, et med.), carried out respectively through front, back walls of an axillary pole and from its highest point; scapular (linea scapularis) — through a bottom corner of a shovel; vertebral (linea vertebralis) — on cross shoots of vertebrae; paravertebral (linea paravertebralis) — through the middle of distance between vertebral and scapular lines. For designation of level of localization of a projection of bodies use top and bottom edges of edges and intercostal spaces. Projections of the major bodies of a chest cavity _ pleurae, lungs, heart can be defined percussion (see), and also by means of roentgenoscopy and a X-ray analysis.


G.'s Pathology, a thorax and bodies of a chest cavity — see. Thorax and articles about the bodies located in a chest cavity, e.g. Aorta , Lungs , Gullet , Pleura , Mediastinum etc. See also articles devoted to individual diseases of these bodies, e.g. Mediastinitis , Pneumosclerosis , Emphysema of lungs etc.


G.'s Damages take place both in military, and in peace time. In peace time they especially often meet at the road accidents, emergencies in mines, at construction works and are on the second place after injuries of extremities. The pathogeny, clinic, diagnosis and the principles of treatment of such damages are similar to fighting damages of G. in this connection they are described jointly. However diagnosis and treatment of fighting damages of G. to field conditions have a row osobennoty, reflected in the present article.

Carry the wounds put with fire or cold weapon, and the closed injuries arising owing to influence of a blast wave at ruptures of air bombs, artillery shells, especially a shockwave of nuclear explosions and also mechanical injuries to fighting damages of G.

G.'s wounds divide on getting and not getting, through and blind. Refer damages at which the integrity of a parietal pleura is broken to getting. They are always followed by pheumothorax — occurrence of air via the wound channel in a pleural cavity (see. Pheumothorax ), and also a hemothorax — accumulation of blood in a pleural cavity (see. Hemothorax ). Among not getting distinguish wounds of a chest wall without damage and with injury of bones (edges and a breast), without damage and with an internal injury (pleurae, a lung, a mediastinum and bodies which are in a mediastinum). Features of pheumothorax (closed, open, valve), the size of a hemothorax (small — to 200 ml, average — to the level of the srednelopatochny line, big — is higher than the level so-so of the scapular line), and also existence of injuries of a skeleton of a chest wall are important for the characteristic of wounds of G.

Among the closed G.'s damages distinguish bruises and prelums of a thorax without injury of bones and internals, single and multiple fractures of edges with an internal injury and development of pheumothorax and a hemothorax. The specified main features of fighting damages of G. were the basis for their classification in days of the Great Patriotic War. In post-war time in it the Soviet surgeons (A. P. Kolesov, M. V. Shelyakhovsky) brought some specifications taking into account which classification is given below.

Classification of wounds and the closed injuries of a breast

A. Wounds of a breast

I. Not getting wounds (through and blind).

1. Without internal injury: a) without injury of bones; b) with injury of bones.

2. With an internal injury: a) without hemothorax, with a small, average hemothorax; b) with a big hemothorax.

II. The getting wounds (through and blind).

1. With wound of a pleura and lung (without hemothorax, with a small, average hemothorax, with a big hemothorax): a) without open pheumothorax; b) with open pheumothorax; c) with valve pheumothorax.

2. With wound of front department of a mediastinum: a) without damage of bodies; b) with injury of heart; c) with damage of large vessels.

3. With wound of back department of a mediastinum: a) without damage of bodies; b) with injury of a trachea; c) with injury of a gullet; d) with injury of an aorta; e) damages of bodies of a mediastinum to various combinations.

B. The closed injuries of a breast

I. Without damage of bodies:

1. Without injury of bones.

2. With injury of bones.

II. With an internal injury:

1. Without injury of bones.

2. With injury of bones.

The given classification has great practical value, especially at mass arrival of wounded since facilitates carrying out medical sorting, helps to estimate a condition of victims and to timely begin pathogenetic therapy.

In days of the Great Patriotic War in separate combat operations of wound of G. made from 7 to 12% of all wounds (S. S. Girgolav, 1951). At the same time the getting wounds met in 42,5% of wounds of G., open pheumothorax was observed in 30,9% of cases, closed — in 68 — 70% and valve — in 1 — 1,5% (P. A. Kupriyanov, 1947).

In army of the USA during the war in Korea (1950 — 1953) of wound of G. made apprx. 8% [Jones (E. Jones), 1968], and in Vietnam (1964 — 1974) — apprx. 9% [N. Rich, 1968].

Due to the improvement of the firearms used by imperialistic armies after World War II in the local military conflicts the destructive force of hurting shells increased and considerably weight of wounds G. Tak increased, in army of the USA in Vietnam among all wounds of G. the getting wounds made 87,9% [Fischer (N. of Fischer), 1968]. In 70% of cases they were followed by the serious condition of wounded connected with existence of a hemopneumothorax [Albrecht (M. Albreht), 1970]. It is necessary to expect increase in frequency and increase of weight and the closed G.'s damages in case of unleashing by imperialists of wars using nuclear weapon. Especially severe injuries can arise from a shockwave, bruises secondary shells (stones, logs etc.), and also at blockages of the destroyed buildings and defensive works caused by nuclear explosions.

A pathogeny

the Majority of not getting wounds and bruises of a thorax without injury of bones and internals are among lungs and, as a rule, are not followed by serious disorders of functions of an organism. The getting wounds, and also the extensive closed G.'s damages belong to the most severe injuries and can pose a threat for life of the victim, direct, in the next and later terms in connection with frequent development of complications. Quite often deaths at G.'s injuries come in the battlefield or at the advanced stages of medical evacuation. At the same time injuries of heart incompatible with life and the main vessels, both lungs, and also blood loss are stated rather infrequently — in 20% of cases of gunshot wounds and in 1,5 — 4% at the closed injury. Weight of a state and lethal outcomes are caused in most of victims by deep functional cardiopulmonary disturbances which expressiveness depends on character and morfol. extensiveness of an injury. However they can reach the menacing degree and at rather small anatomic damages.

Most often there are menacing disorders of function of external respiration leading to development of acute respiratory insufficiency (see). To 50% of wounded perish in connection with these frustration. The leading role in genesis of acute respiratory insufficiency belongs to the disturbance of biomechanics of breath connected with changes of intrapleural pressure, pain and disturbance of an integrity of a thorax. At the getting wounds the greatest direct danger is constituted by open pheumothorax, and also valve pheumothorax which is followed by the increasing intrathoracic pressure.

Obstruction of bronchial tubes clots or slime in connection with hypersecretion of a phlegm and suppression of a tussive reflex because of pain and damage of a chest wall therefore there is alveolar hypoventilation, focal atelectases and aspiration bronchial pneumonia can be other cause of acute respiratory insufficiency. The progressing anoxemia is a consequence of these disturbances (see. Hypoxia ) and hypercapnia (see) which in combination with obturation of bronchial tubes cause emergence hypertensia of a small circle of blood circulation (see), dysfunction of surfactant of an alveolar epithelium (see. Surfactant ) and increase in intersticial and intra alveolar transudation (syndrome of «a wet lung»). At considerable blood loss and shock there can be disturbances of microcirculation in lungs that is promoted by also excess transfusions of isotonic salt solutions and plasma substitutes, to stored blood of long terms of storage.

Especially heavy course of acute respiratory insufficiency is observed at multiple fractures of edges in combination with damage of intrathoracic bodies («the injured breast»), at splintered fractures of edges (front and lateral), with formation of an unstable fragment of a thorax («the costal valve»).

Other heavy complications of a thoracic injury are: bleeding, contusions of heart and a hemopericardium from accruing cardiac tamponade (see). Character and extent of functional disturbances at G.'s wounds to a great extent depend on the size of a hemothorax. Reduction of volume of the circulating blood as a result of acute blood loss causes a transport anoxemia.

Since at the same time there is also a ventilating anoxemia caused by disturbance of external respiration, blood loss badly is transferred by wounded. The blood which streamed in a pleural cavity, squeezing a lung, reduces its respiratory surface, displaces a mediastinum in the healthy party that leads to disturbance of cordial activity and reduction of a respiratory surface of a healthy lung. All this aggravates the anoxemia which is available for the wounded and leads to further deterioration in the general state.

Thus, the most important consequence of injuries of a thorax making them patofiziol, essence, heavy changes intrathoracic anatomo-fiziol, balances, cardiopulmonary frustration and blood loss which cause emergence of respiratory insufficiency of various origin, including and a transport anoxemia with the subsequent development of shock and metabolic disturbances are.

The clinical picture and diagnosis of damages

the Clinical picture and diagnosis of damages of G. depend on the nature of wound (damage). The final diagnosis and conclusion about weight traumatized, about terms and the final stage of treatment of the victim it is possible to make only at stages where there is a qualified and specialized medical aid.

Not getting wounds in most cases belong to lungs. Outcomes of such wounds of G. in most cases favorable.

However a part of these wounds which are followed by a bruise or a rupture of tissue of lung from influence of force of side blow of a fire shell shall be carried to heavy. At the same time can be pneumorrhagia (see), and in certain cases and hemothorax. Wounds with extensive destruction of soft tissues and a skeleton of a chest wall or injury of intercostal and internal chest arteries always are heavy. Wound of these vessels usually is followed by considerable bleeding.

Wedge, a picture and course of getting G.'s wounds are defined first of all by the nature of pheumothorax and size of a hemothorax. At wounds without open pheumothorax a wedge, a picture it is very characteristic. The wound of a chest wall of usually small sizes, in its circle is available, as a rule, hypodermic emphysema (a swelling, a crunch at a palpation). Perkutorno is defined a tympanites, and at development of a hemothorax — dullness in lower parts of a thorax on the party of wound. Auskultativno comes to light sharp weakening of respiratory noise. At rentgenol, a research establish existence or lack of injury of bones of a thorax, extent of fall of a lung and shift of a mediastinum in the healthy party, and also size of a hemothorax. At nonperforating wounds specify localization of a foreign body (a hurting shell).

Wounds with open pheumothorax proceed much heavier. In addition to the symptoms described above, quite often there is expressed short wind, cyanosis of integuments, motive excitement. The wounded holds forced position with the raised upper half of a trunk. Pulse is usually frequent, weak filling. The ABP can be raised in the beginning, and then decreases. At survey of a wound suction of air on a breath and the allocation of air traps from it during an exhalation which is followed sometimes by the characteristic sucking noise is defined. In a circle of a wound, as a rule, there is hypodermic emphysema (see). At widely gaping wounds of a chest wall fragments of the injured edges and the fallen-down lung sometimes are visible. The habit view of the wounded and a condition of a wound at open pheumothorax are so characteristic that the diagnosis usually does not raise doubts, and additional inspection aims to specify only degree of a collapse of a lung and shift of a mediastinum, size of a hemothorax, localization of a foreign body at nonperforating wounds etc. Most informatively in this respect rentgenol, research of a thorax.

The heaviest are wounds with valve pheumothorax. Clinically valve pheumothorax is characterized by heavy, life-threatening disturbances of breath and blood circulation. The general condition of the wounded can quickly worsen. Appear the expressed expiratory asthma (see), cyanosis of integuments and mucous membranes and motive excitement. An asthma and breath have a peculiar character. The wounded tries to hold the breath on a breath since at an exhalation the thorax decreases in volume and in addition squeezes already squeezed lungs both on damaged, and on the healthy party. Blood pressure increases in the beginning, and then quickly decreases. The pulse in the beginning strained in the subsequent becomes speeded up, weak filling. There is sharply expressed hypodermic emphysema, edges can extend to a trunk, a neck, the head and extremities. Emphysema of a mediastinum since it leads to a prelum of heart and large vessels is very dangerous and aggravates disturbances of cordial activity (see. Pneumomediastinum ). Radiological at valve pheumothorax the total collapse of a lung on the party of wound, the sharp shift of a mediastinum in healthy side and narrowing of the pulmonary field on the healthy party comes to light. As a result of developments of stagnation transparency and a healthy lung decreases.

Clinically it is not always easy to distinguish a hemothorax though at the same time there are always symptoms of acute blood loss, a dullness and sharp weakening of respiratory noise over lower parts of a thorax on the party of wound. Most authentically the hemothorax is diagnosed radiological; in pictures and at raying of a thorax in a pleural cavity the shadow of liquid with slanting level (is visible at a hemopneumothorax — with horizontal level). The final diagnosis of a hemothorax is established with the help pleurocentesis (see), in time a cut receive blood. It is desirable to carry out a puncture after localization and the sizes of a hemothorax radiological are specified. A small amount of liquid in a pleural cavity (less than 200 ml) neither clinically, nor radiological usually

a wedge it is not possible to reveal. The picture of the closed G.'s injuries, including the heavy, followed internal injury and development of pheumothorax and a hemothorax, significantly does not differ from described above. However they proceed much heavier and are followed by higher figures of a lethality. This results from the fact that at extensive stupid injuries of G. a zone of destruction of fabrics of a chest wall (multiple fractures of edges, injuries of muscles and internals), separations and ruptures of easy and large bronchial tubes, injuries of heart and other bodies of a mediastinum much more, than at wounds.

At the closed G.'s injuries, especially heavy, in a wedge, a picture into the forefront the phenomena of respiratory insufficiency which develop generally as a result of reduction of a respiratory surface of lungs and disturbance of tracheobronchial passability also act. Quite often weight of a condition of victims is caused by a bruise of heart or massive blood loss from the damaged vessels of a chest wall, a lung and a mediastinum, and also the shift of a mediastinum in the healthy party as a result of development of a hemopneumothorax. Ruptures of a diaphragm, a gullet, a pericardium and damage of other bodies of a mediastinum are much less often observed.

Complications of not getting G.'s damages most often meet in the form of osteomyelitis of bones of a thorax (see. Osteomyelitis ), okoloranevy phlegmon, traumatic pleurisy. Complications at the getting wounds in most cases have pyoinflammatory character and quite often develop in shape is purulent - septic processes. Usually they arise during the period from 5 to 15th day after wound. In days of the Great Patriotic War occurred among complications of fighting damages of G. shock (see), the pheumothorax which for the second time opened, pneumonia (see), an acute empyema of a pleura (see. Empyema ), sepsis (see), mephitic gangrene (see), bronchial fistulas (see. Bronchial fistula ), gangrene and abscesses of lungs (see. Lungs ), osteomyelites of bones of a thorax, etc. Data on the frequency of some complications at getting G.'s wounds in days of the Great Patriotic War are provided in the table.

Frequency of complications at the getting wounds of a breast as a percentage to total number of the getting wounds of a breast (according to A. A. Bocharov, 1949)

Treatment of wounds and the closed injuries

Treatment of wounds and the closed G.'s injuries, especially heavy, shall be directed first of all to recovery fiziol, balances, elimination of the reasons of the menacing state and the prevention of late complications. For this purpose it is necessary to begin vigorous carrying out a complex of resuscitation measures in perhaps early terms. The major among them: sealing and an immobilization of a chest wall (a bandage, sewing up of a wound), an early and full-fledged decompression of a pleural cavity (see. Drainage ), ensuring free passability of respiratory tracts (see. Bronkhoskopiya , Intubation , Tracheostomy ), raspravleniye of a lung, completion of blood loss, antishock and anticoagulating therapy, insufflation of oxygen, use of analgetics and antibiotics. Quite often methods, rather simple and available to the advanced stages of medical evacuation, at the correct and their consecutive use help much of victims to cope with directly life-threatening patofiziol, the frustration caused by an injury well to transfer transportation to stages where there is a qualified and specialized medical aid.

For prevention of a wound fever it is necessary to execute perhaps earlier primary surgical treatment of a wound of a chest wall, a lung and bodies of a mediastinum. At not getting, and also getting G.'s wounds without open pheumothorax surgical treatment of a wound of a chest wall is made according to the general indications taking into account the nature of wound.

In the presence of open, and also valve pheumothorax surgical treatment and sewing up of a wound of a chest wall is shown. After sewing up of a wound of a chest wall tightly the valve ceases to function. At internal valve pheumothorax constant drainage and aspiration of air and liquid from a pleural cavity within 3 — 5 days is carried out. If the valve does not cease to operate, is shown thoracotomy (see) with surgical treatment and sewing up of a wound of a lung.

Blood shall be removed from a pleural cavity in perhaps early terms for the purpose of a bystreyshy raspravleniye of the fallen-down lung. Small accumulation of blood (a small, average hemothorax) can be aspirated by means of punctures or drainage of a pleural cavity; chlorvinyl tube. At a big hemothorax for the purpose of a stop of internal bleeding, and also in cases of identification in a lung, in a pleural cavity or in a mediastinum of a large foreign body (a bullet, a splinter) the thoracotomy is shown.

Treatment of the closed G.'s injuries is carried out by the same principles, as treatment of wounds. At slight injuries and G.'s prelums, and also changes of one — two edges without internal injury a short-term bed rest, alcohol - novocainic blockade to places of a fracture of edges, administration of drugs and cardiovascular analeptics quickly lead to improvement of a condition of victims.

At severe closed G.'s injuries apply analgetics to elimination of disturbance of external respiration, suck away a phlegm and blood from a trachea and bronchial tubes, and if necessary carry out a toilet bronkhoskopiya. In cases of inefficiency of these actions impose a tracheostoma, through to-ruyu systematically suck away a phlegm for the purpose of recovery of tracheobronchial passability. Through a tracheostoma by means of a catheter give oxygen to a gleam of a trachea. In the presence of a hemopneumothorax tactics of the surgeon is similar to tactics at the getting wounds of.

At double (fenestrated) fractures of edges mobility of the damaged site of a chest wall try to obtain elimination patol. For this purpose apply skeletal traction for edges or a breast or extension for soft tissues in the field of costal «valve», and in certain cases carry out external fixing of the mobile site of a chest wall. If use of these methods is impossible, apply so-called internal stabilization costal «of the valve» by means of long (up to 10 — 25 days) artificial ventilation of the lungs (see. Artificial respiration , artificial ventilation of the lungs).

Stage treatment. The volume of medical aid at G.'s damages at stages of medical evacuation to a field situation and in the conditions of GO includes holding certain medical and evacuation actions.

In the battlefield (in the centers of mass defeat) actions of the first and pre-medical medical aid include imposing of a bandage on a wound, administration of pantopon and other drugs (except morphine). At the getting wounds, especially with open or valve pheumothorax, it is necessary to apply occlusive (occlusal) dressing on a wound for what use the rubberized cover of a first-aid dressing kit (see. Package dressing individual ) or any sterile plastic film. At heavy disturbances of breath carry out an artificial respiration by method of companies to a mouth or by means of a S-shaped tube.

In all cases of victims it is necessary to evacuate in perhaps shorter time in regimental medical aid station (see), and it is better directly in medical and sanitary battalion (see) OMO, and in the conditions of GO — in OPM (see. Group of first aid ).

The first medical assistance aims to reduce by PMP first of all danger of life-threatening disturbances of breath and blood circulation. It includes control and correction of bandages, especially occlusal, at wounded with open and outside valve pheumothorax, vagosympathetic blockade at the expressed disorder of breath, transfusion of small doses of blood and blood substitutes, introduction of antibiotics, narcotic and cardiovascular means. G. which were injured with damages evacuate in MSB (OMO) first of all.

The qualified surgical help in MSB (OMO) aims at further fight against disturbances of breath and cordial activity, a final stop of nanuzhny and internal bleeding and completion of blood loss. Treat the actions of the qualified medical aid which are carried out in MSB (OMO) according to vital indications: complex antishock therapy, sewing up of open pheumothorax, surgical treatment and sewing up of a wound of a chest wall at outside valve pheumothorax, drainage of a pleural cavity at internal valve pheumothorax. In case of development of emphysema of a mediastinum make a section over cutting of a breast and drain a front mediastinum. For the purpose of a stop of intrapleural bleeding at victims with a big hemothorax carry out a thoracotomy and primary surgical treatment of a wound of a chest wall, a lung and bodies of a mediastinum.

At disturbances of external respiration and development of a syndrome of «a wet lung» (a heavy asthma, cyanosis, the rattling and bubbling breath, mental and motive excitement) carry out transnasal catheterization of a trachea and bronchial tubes and suck away a phlegm and blood from upper respiratory tracts; if necessary impose a tracheostoma, give oxygen, carry out the managed breath, carry out various type of blockade. All wounded enter repeatedly antibiotics and evacuate in specialized hospital.

In OPM there is a medical aid in the same volume, as well as on PMP. If the situation allows, then it is expanded to the events held in MSB. Specialized medical aid includes final diagnosis and treatment of damages, and also the developing complications. It includes rentgenol, a research of a thorax, a bronkhoskopiya, diagnostic pleurocenteses, on indications active aspiration of air, blood and exudate from a pleural cavity for the purpose of a raspravleniye of a lung. At inefficiency within 3 — 5 days of conservative treatment carry out a thoracotomy and take in defects of tissue of lung. The thoracotomy is made concerning the proceeding intrapleural bleeding, and also in cases of development of the massive curtailed hemothorax; perform treatment of early and late complications of wounds and the closed G.'s injuries (atelectases of pulmonary fabric, pneumonia, pleurisy, an empyema of a pleura, abscess of a lung, etc.).

After a thoracotomy and other surgical interventions on bodies of a thorax most of victims will be able to return to a system not earlier than in 5 — 6 months, and many of them are subject to dismissal from army. Therefore it is reasonable to evacuate this group of victims after removal from serious condition in hospital of the back of the country.

G. which were injured with slight injuries, napr, with not getting wounds of soft tissues of a chest wall or uncomplicated changes of one — two edges, after specification of nature of damage and assistance (primary surgical treatment of a wound, blockade, etc.) can go for the subsequent treatment in hospital for lightly wounded (see).

Bibliography: Wagner E. A. Surgical treatment of the getting wounds of a breast in peace time, M., 1964, bibliogr.; it, the Getting wounds of a breast, M., 1975, bibliogr.; Vishnevsky A. A. and Shrayberm. I. Field surgery, M., 1975; To foresters And. Page and P at t about in P. V. O treatment of injuries of a breast in the conditions of modern war, Voyen. - medical zhurn., No. 7 * page 12, 1964; H and d. Surgical anatomy, the Thorax, the lane with Wenger., Budapest, 1962, bibliogr.; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 9 — 10, M., 1949 — 1950; Surgical anatomy of a breast, under the editorship of A. N. Maksimenkov, L., 1955, bibliogr.; Shelyakhovsky M. V. and Zheg'alov V. A. Objem of medical care at stages of evacuation at the closed injuries of a breast, Voyen. - medical zhurn., No. 6, page 9, 1974; Shelyakhovsky M. V. and Lunin M. M. Organization of treatment of victims with the getting wounds of a breast at stages of medical evacuation, in the same place, No. 9, page 13, 1973, bibliogr.; F e Ison B., Weinstein A. S. u. Spitz H. B. Rontgenologische Grundla-gen der Thoraxdiagnostik, Stuttgart, 1974; NaclerioE. A. Chest injuries, N. Y. — L., 1971, bibliogr.; Rich N. M. Vietnam missile wounds evaluated in 750 patients * Milit. Med., v. 133, p. 9, 1968.

A. P. Kolesov, M. V. Shelyakhovsky; S. S. Mikhaylov (An.).