FOREIGN BODYS (corpora aliena) — objects or parts them, alien to an organism, got to it as a result of damage of covers or through natural foramens and remained in fabrics, the closed perigastrium or in a gleam of hollow body, and also various endoparasites formed in bodies concrements and some insects.
- 1 GENERAL INFORMATION ABOUT FOREIGN BODYS
- 2 FOREIGN BODYS of the HEAD AND SPINAL CORD
- 3 FOREIGN BODYS of an EYE
- 4 FOREIGN BODYS of the THROAT AND GULLET
- 5 FOREIGN BODYS of the THROAT, TRACHEA AND BRONCHIAL TUBES
- 6 FOREIGN BODYS of a throat and upper respiratory tracts, first aid and resuscitation
- 7 FOREIGN BODYS OF BODIES OF THE CHEST CAVITY AND DIAPHRAGM
- 8 FOREIGN BODYS of DIGESTIVE TRACT AND ABDOMINAL CAVITY
- 9 FOREIGN BODYS of the BLADDER AND the URETHRA
- 10 FOREIGN BODYS of the VAGINA AND UTERUS
GENERAL INFORMATION ABOUT FOREIGN BODYS
Most often And. t. get to an organism through the damaged covers as it happens at wounds. They can be primary (bullets, splinters, pieces of glass, a needle) and secondary (the scraps of clothes, footwear, pieces of the earth, etc. which are carried away in fabric by a hurting subject or scattered by force of explosion). Through natural foramens of a body And. t. get usually accidentally, but sometimes enter them purposely. Some And. t. enter into an organism with to lay down. purpose: alloplastichesky prostheses (see. Alloplasty ), metal (tantalic are more often) and the plastic nails, spokes, plates and other fixers fastening fragments of bones, silk ligatures, drainages, etc.
In total And. t. (except entered with to lay down. the purpose) are to a greater or lesser extent contaminated by microorganisms.
Low-infected, chemically and biologically inert And. t. at rather small zone of damage of fabrics often do not cause essential inflammatory reaction and are encapsulated, acquiring connecting fabric. Encapsulated And. t. can remain in an organism, without causing almost any a wedge, symptoms for many years. But it is even long being in fabrics I. t. under the influence of provocative circumstances (the bruise, infectious diseases and other factors reducing the general body resistance) are capable to cause suppuration owing to activation of autoinfection. At considerable microbic pollution unextracted And. t. can cause suppuration and support its long hron, a current with education not healing or periodically opening fistulas (see). Treatment in such cases perhaps, as a rule, only after removal And. t. However in some cases there can be a zatikhaniye of suppurative process. And. t. at the same time are surrounded with a thick piogenic cover, inside the cut contains washing And. t. the pus most of which often is not giving growth of microflora at crops. Such «cold» conditionally sterile abscesses can be formed around thick silk ligatures. They rather easily give flash of an aggravation of suppurative process, causing in the subsequent, sometimes through considerable terms, suppuration with break of abscesses and formation of alloyed fistulas. Abscesses around ligatures quite often find at various repeated surgeries.
And. t., located near large arteries, sometimes lead to destruction of their walls with development of pulsing hematomas (see) or outside (arrosive) bleeding via the wound channel or the fistular course. And. t., located about nervous trunks and in places which owing to various reasons are exposed to supertension (a palmar surface of a brush, a bottom surface of foot, area of knee and elbow joints, buttocks, a waist etc.), can cause pain and break function. And. t., being freely in a cavity of a joint, often lead to restriction of its mobility and so-called blockade of a joint. Reactive And. t. (fragments of a core of a chemical pencil, crystals of potassium permanganate, turpentine, etc.) cause a necrosis of surrounding fabrics. And. t., the containing toxic agents, are capable to cause the general intoxication. Radioactive And. t. cause focal radiation lesions with a necrosis of fabrics and an ulceration.
Ideas of a possibility of migration And. t. quite often happen exaggerated. Formed around And. t. the fibrous capsule does not allow them to be displaced even at reduction of muscles. Essential shift And. t. it is not observed also before formation of the strong cicatricial capsule. It belongs also to sewing needles. Are capable to migrate And. t., implemented into a large blood vessel (needles, scraps of a catheter), and also needles getting into tendinous vaginas or serous cavities. Migration is possible And. t. in a gleam went. - kish. a path (including and antiperistaltic) and on respiratory tracts.
In diagnosis And. t. the anamnesis is of great importance (the instruction on a proglatyvaniye or introduction And. t. in this or that natural foramen, an explanation of nature of wound).
To suspect existence And. t. soft tissues survey, a palpation allow. The through wound channel does not exclude existence And. t. Sometimes the bullet, a metal splinter can lie from entrance gate at a great distance, and in some cases be away from an estimated projection of the wound channel (e.g., at change of the direction of the movement of a bullet after blow in a bone). X-ray contrast And. t. reveal with the help rentgenol, methods of a research. Help in detection radiological low-contrast and low-contrast And. t. the ultrasonic biolocation can render (see. Ultrasonic diagnosis ), and in the presence of fistulas — a fistulografiya. Great value in diagnosis And. t. hollow bodies have different types of endoscopy. It is long fistulas, not healing after wound, long not resolving infiltrates as well as late suppuration in the field of the healed wound, is often pointed to existence And. t. It is important to determine not only the fact of existence And. t., but also its exact localization and relationship And. t. with the next anatomic educations that the wedge, and rentgenol, inspections is facilitated by use complex.
Pathoanatomical changes in fabrics and bodies at implementation And. t. forms, chemical structure, degree of microbic impurity and character are various and depend on the sizes, And. t., the term of its stay in fabrics and bodies, and also from anatomic and gistol, structures And. t.
Not contaminated by microorganisms and chemically inactive And. t. causes only bruises of fabric elements with release of biologically active agents. Around And. t. there is an inflammatory and hyperplastic reaction. Histologically in the next few hours and days after implementation in fabric I. t., in addition to hemorrhage, staza of leukocytes in capillaries come to light, swelled also infiltration by segmentoyaderny leukocytes, leukocytes show phagocytal activity. There is a proliferation lymphoid, epithelioid and plasmocytes; from histiocytes macrophages polyblasts, people around develop And. t. Are formed of macrophages polyblasts specific to presence And. t. colossal cells (see), received the name «colossal cells of foreign bodys». Soon the exudative phenomena abate and around And. t. the fibrous capsule develops. Around And. t. the small sizes the created capsule is found in 2 — 3 weeks after an injury. Even at long-term existence of the capsule around some And. t. in it there is a constant reorganization which is expressed in change of dystrophic and reparative processes (see. Regeneration in pathology ).
Contaminated by microorganisms And. t. can cause a purulent inflammation with formation of abscess, at break to-rogo perhaps formation of fistulas. At damage And. t. mucous membranes of various bodies ulcers which form and an arrangement depend on a structure of body and character are formed And. t. In the field of ulcers adjournment of fibrin, a sharp plethora of fabrics, and later purulent infiltration is noted.
Biol. And. t. (hair, bones) are steady against enzymatic influences and are well encapsulated. And. t., the containing fats, cause development of paraffinomas (see. Lipogranuloma ). Chemical structure metal And. t. defines color of the capsule around it. Dominance of iron gives to the capsule a rusty-brown shade, and copper — greenish.
The suture material used in surgical practice causes various reaction of fabrics. Around silk threads exudative reaction, the most pronounced on the first week develops. Around threads of silk there are giant-cell granulomas (fig. 1) — specific granulomas (see), consisting of «colossal cells of foreign bodys». On the 2nd week there is an organization of the young granulyatsionny fabric getting and between threads of silk. On 3 — 4th week around a ligature the rough connective tissue capsule remaining for years forms. Fibers of a catgut in fabrics already as soon as possible are exposed to swelling and early infiltration by segmentoyaderny leukocytes. On 4 — the 5th day of fiber of a catgut lose the durability and resolve on 7 — the 30th day. Among the applied suture materials the smallest fabric reaction is caused by threads of a chrome-plated catgut (fig. 2 and 3), the catgut processed by chloride sulfate; they do not bulk up, and rezorbirutsya on perimeter, keeping durability up to 70 days. In the fabrics surrounding catgut thread there are no centers of a necrosis and an inflammation that warns from eruption of seams. Weak leukocytic infiltration and encapsulation by the end of the week is observed around kapron threads which rassasyvaniye does not come also in one and a half years.
Introduction of gauze tampons to serous cavities leads to early loss of fibrin that accelerates formation of commissures. Histologically at the same time weak leukocytic infiltration and proliferation of connective tissue elements comes to light. The rubber drainages left in serous cavities quickly become covered with fibrin, but commissures around them develop a little. Chlorvinyl drainages cause weak macrophagic reaction and almost encapsulations are not exposed.
During the use for prosthetics of blood vessels of biologically inert ftorolon materials, teflon and a Dacron a liquid part of blood gets through a time of material, forming a proteinaceous coagulant which will be organized over time, and the inner surface of a prosthesis is covered by an endothelium, coming from zones of an anastomosis. Prostheses from propylene and capron cause hron, an inflammation with moderate giant-cell reaction, edges is traced for several years.
At hit And. t. in an eye character patol, process generally is defined by chemical structure And. t. and its contamination. At infected And. t. in an eye the purulent inflammation develops.
And. t. respiratory tracts can lead to acute asphyxia (see) owing to obstruction of a gleam of a throat or a trachea. At hit And. t. in gleams of bronchial tubes decubitus of a mucous membrane is quickly formed. Even superficial decubitus of a bronchial tube is dangerous because of inevitable accession of the infection extending both in descending, and in the ascending direction with the subsequent development of bronchitis, a peribronchitis (see. Bronchitis ) and abscessing pneumonia (see). Rather rare And. t. bronchial tubes the broncholiths which are formed at treatment by lime of a lump of slime of a pla of pus are (see. Broncholithiasis ). Stones of bronchial tubes do not reach the big sizes, are brittle, sometimes repeat a form of a branching of bronchial tubes.
At hit And. t. in easy changes arise not only in a zone of stay And. t., but also around the wound channel, especially in a zone of contact with walls of bronchial tubes and vessels, i.e. on border of various fabrics. Close And. t. there is a zone of a necrosis, and the zone of hemorrhagic treatment of a lung is farther. On second day around the center the leukocytic shaft with signs of its organization from third day after an injury is found. To the middle of the second week in the absence of an infection the wound channel is filled with quickly organized granulyatsionny fabric. By the end of month around And. t. the fibrous capsule, an inner surface a cut develops it is often covered by the epithelium getting here from adjacent bronchial tubes. In the thickness of the fibrous capsule small bronchial tubes, alveolar partitions and a large number of vessels for many years remain. Walls of vessels undergo considerable changes of both dystrophic, and inflammatory character which are dangerous because of possible developing of bleedings. In surrounding tissue of a lung the picture hron, inflammations with the centers develops pneumosclerosis (see), purulent bronchitis and bronchiectasias (see). Single observations of cancer of the lung which developed close are described And. t. in several decades after wound.
And. t. hearts are rare, are located in the thickness of his muscle more often, is more rare in cavities. And. t. can get into heart as a result of wound (bullets, splinters, sewing needles) or enter them with to lay down. purpose (artificial valves, electrodes of a pacemaker).
Directly after implementation And. t. in a muscle of heart around it sites of hemorrhages and a zone of a necrosis are found. If inflammatory reaction, then does not develop around And. t. the capsule is formed. Even at a long arrangement And. t. in a myocardium in the capsule around And. t. it is possible to find focal lymphoid infiltrates. Encapsulated And. t. hearts can be more often an accidental find on section. Development around And. t. leads inflammations to purulent complications: to myocarditis, a pericardis or a pancarditis with the subsequent fibrous obliteration of a cavity of a pericardium.
At a vshivaniye of ball prostheses of valves of heart in the first days on their surface adjournment of fibrin and uniform elements of blood with an aseptic inflammation in surrounding fabrics appears. The first signs of the organization around a prosthesis are found by the end of the week when during a time of a prosthesis fibroblasts burgeon. On the 2nd week after operation around a prosthesis the capsule is formed of argyrophil fibers.
Speed of formation of the capsule around a prosthesis in the first 3 months depends on conditions of a hemodynamics and from biol, activities of material. The capsule forms in the right half of heart quicker. By 6 months encapsulation of a synthetic prosthesis of the valve connective tissue elements comes to light.
And. t. a gullet with keen edges (meat, bird's, fish bones, needles, splinters of glass, etc.) at implementation or unsuccessful attempts of their removal lead to developing of a wound of a mucous membrane of a gullet or even damage of all layers of its wall. These wounds are found in an upper part of a gullet more often, usually have a longitudinal arrangement, their edges are raised and impregnated with blood. In a wall of a wound because of bacterial pollution the purulent inflammation quickly develops. Histologically in the next few hours hypostasis and hemorrhages in a wall of the wound channel and the infiltration by segmentoyaderny leukocytes extending to different depth is found. Firm And. t. without keen edges can lead to formation of decubituses of a mucous membrane with development in some cases purulent esophagitis (see).
Among And. t. a stomach dentures, spoons, forks, needles and other objects with keen edges are most frequent. Long stay And. t. in a stomach leads to an inflammation of a mucous membrane, an ulceration and decubitus of a wall, up to its perforation. Under the influence of a gastric juice acute contours And. t. a stomach can smooth out.
And. t., not digested by a gastric juice at long stay in a stomach, sometimes form gastric stones (fig. 4), or bezoara (see). Long stay of bezoar and increase in their sizes leads to a hypertrophy of walls and expansion of a gleam of a stomach. The bezoar can be the cause of formation of decubitus, stomach ulcer (see. Peptic ulcer ) and pylorostenosis (see). Carry to rare complications of bezoar bleeding and perforation of walls of a stomach.
Among And. t. intestines the objects swallowed by patients, gallstones, intestinal parasites meet more often. And. t. the small sizes can it is long to be located in a gleam of a gut and to get stuck only in places fiziol, narrowings. M.'s implementation t. in a wall of a gut leads to an inflammation in it, after subsiding to-rogo in various layers of a gut sometimes remain encapsulated And. t. Foreign bodys of an acute form and the small sizes can get into a wall of a gut without noticeable injury of a mucous membrane and be the cause of a «inflammatory» tumor of the gut which is gradually narrowing its gleam. Prelum of a wall of a gut occlusive And. t. leads to an ulceration of her mucous membrane. And. t. the big sizes can cause obturatsionny impassability (see. Impassability of a kishechkik ).
And. t. an abdominal cavity most often there are gauze napkins or surgical instruments left at an operative measure. Around gauze tampons from the first days of their stay the inflammation which early is replaced by productive reaction with formation of specific granulomas with existence of «colossal cells of foreign bodys» and quickly developing commissures develops. Metal tools acquire the thin fibrous capsule limiting their movement. Around rubber drainages of commissures it is formed less.
And. t. a bladder, the having keen edges, can be implemented into a wall of a bubble and be the cause of its perforation with education an uric zatek (see). Long being in a bubble And. t. lead to formation of decubituses with the subsequent emergence of diverticulums of a wall of a bubble. Hit in a bladder And. t. promotes development cystitis (see). And. t., it is long being in a cavity of a bladder, are usually inlaid with urate salts.
And. t. vaginas cause development of a purulent vaginitis (see. Colpitis ), accepting often hron, a current. And. t. the large sizes of a dense consistence can lead to decubitus of a back wall of a vagina with the subsequent development of phlegmon of a basin.
And. t. leads a uterus to development of an endometritis and a myometritis (see. Metroendometritis ). The organization of the fetal membranes which remained in a uterus can be the cause of formation of placental polyps (see. Placental polyp ).
Clinic and diagnosis And. t. it is presented in chapters devoted to separate bodies.
the Purpose rentgenol, researches at suspicion on existence And. t. — detection And. t., determination of their quantity, the sizes, forms, character, anatomo-topographical situation, studying of a condition of bodies and fabrics in the place implementation And. t. and in the neighboring areas, and also identification possible a complication, connected with implementation And. t. in an organism. Possibilities of radiodiagnosis are in direct dependence on size and chemical structure And. t. Metal And. t. cause easily distinguishable shadows on the roentgenogram. Low-contrast And. t. come to light at carefully carried out special rentgenol, inspection by a special technique and high quality of pictures.
At radiodiagnosis And. t. use roentgenoscopy, a X-ray analysis and electrox-ray analysis (see), and according to indications and some special types rentgenol, researches, such, as tomography (see), rentgenokimografiya (see), X-ray cinematography (see), X-ray polygraphy (see. Polygraphy ), stereox-ray analysis (see), fistulografiya (see) etc.
Rentgenol, ways of definition of localization And. t. divide into three basic groups: 1) geometrical ways; 2) anatomo-topographical ways; 3) the X-ray surgical ways applied at operations of removal And. t.
Geometrical ways come down to definition of a depth And. t. from the surface of a certain site of skin or from the set anatomic reference point. The greatest distribution was gained following from them.
The method of rotation is carried out at raying and is that at turns behind the screen of the explored area (e.g., the heads, extremities) define situation, at Krom a shadow And. t. is at the smallest distance from the surface of skin. This distance from a shadow And. to a tag on skin corresponds to a depth And. t. The method is shown at a superficial arrangement And. t.
The method of four points consists in overlaying on skin at raying of four metal tags located so that each couple of tags was in one plane with And. t., and in relation to other couple — at right angle. Contours of the studied object and a projection of tags on it are transferred to paper. Having connected in the drawing opposite couples of points straight lines, define a projection And. t., being on crossing of these two straight lines.
The method of parallel shift of the screen and a tube allows to calculate a depth And. t. on the basis of calculation of parallactical shift of a shadow And. t. at the movement of a X-ray tube in the plane parallel to the screen or a film (see. X-ray analysis ).
The method of double pictures is based on double exhibiting of one film, and the second picture is made after the shift of a tube parallel to the plane of the cartridge on a certain distance at a motionless object of a research. At the same time on a film the double image turns out And. t. Depth of its bedding is defined by the formula following from similarity of the triangles formed by the size of shift of a tube, shift of a shadow And. t. in a picture, depth of its bedding and distance between focus of a X-ray tube and a film. The way of double pictures has numerous modifications. For simplification of calculations special tools, tables, devices were offered (see. Freydina ruler ).
Anatomo-topografichesky ways establish relationship between And. t. and certain anatomic educations or bodies. For this purpose apply Polyposition research (see) and a X-ray analysis in combination with a tomography. At the same time consider possible movements And. t., caused by reduction of muscles, cardiac performance, the respiratory movements of edges, diaphragms and shifts And. t. in connection with a postural change of a body of the patient or under the influence of a palpation. According to indications apply special methods of a research — a rentgenokimografiya, X-ray cinematography, X-ray polygraphy, angiocardiography.
The X-ray surgical ways used during operational removal And. t., are based on definition of anatomo-topographical situation it by means of the corresponding x-ray equipment, thanking a cut the surgeon has an opportunity to delete And. t. under control of raying. Use of X-ray apparatus with electron-optical amplifiers and television screens considerably expanded possibilities of use of these ways.
X-ray inspection of extremities. Research problem is as definition of a depth And. t., and its anatomo-topographical localization in soft tissues, bones or joints. According to the roentgenograms executed in two mutually perpendicular projections approximately establish location And. t., sometimes applying additional pictures in optimum projections, in particular tangential.
During the bendings and extensions, rotation, reduction or assignment of an extremity And. t. it is, as a rule, displaced along with reduction or relaxation of the corresponding group of muscles. At intra bone localization a shadow And. t. at multiaxial raying or to series of pictures it is not brought for contours of a bone. In some cases, presenting difficulties for definition of intra bone localization And. t., resort to a tomography. About intra bone localization And. t. the symptom of «aura» — the decompression section or, on the contrary, consolidations of bone structure testifies around And. t.
At an intra joint arrangement And. t. its shadow does not manage to be removed for contours of a joint. For definition of intra joint localization And. t. the tomography in combination with a pnevmoartrografiya is important (see. Artrografiya ). Convincing sign of an intra joint arrangement And. t. its moving to cavities of a joint at a postural change of an extremity is.
At localization And. t. in close proximity to vessels its pulsatorny shifts synchronously with a pulsation of a vessel which degree is more than subjects, than closer are noticeable And. t. to a vessel and than the vessel is larger. Angiography (see) allows to define more precisely a relative positioning of vessels and And. t.
At the suppurative processes connected with implementation infected And. t. and the fistulas which were complicated by education, apply a fistulografiya to specification of the diagnosis.
At radiodiagnosis And. t. always it is necessary to use the most effective method for this case along with localization And. t. to establish the possible accompanying damages that is especially important at so difficult gunshot wounds in the topographical relation of areas as the head, a breast, a stomach, a basin.
At serious condition of the victim it is necessary to use the sparing methods, avoiding excessive movements of the patient, using the corresponding movements of a X-ray apparatus and the Polyposition research.
X-ray inspection of children. The technique of a research of children as they in X-ray department often behave uneasily shall be especially sparing, but also, differ in hypersensitivity to x-ray emission. The successful research of children of advanced age is helped by the quiet and tender address, and to children of younger age use the special fixing devices and devices. The dose decline of radiation of children is reached by use of hard rays with short endurance at pictures and careful protection of a body of the child, especially gonads, from not used and secondary radiation by means of special patterns from the leaded rubber. Use of the electron-optical amplifier (see. X-ray apparatus ) and X-ray television (see. Television in medicine ) sharply reduces an exposure dose of children, especially at X-ray surgeries of removal And. t.
Removal of foreign bodys
Extraction And. t. from soft tissues as soon as possible after their implementation it is shown in all cases when it is rather easily feasible and is not accompanied by drawing a considerable additional injury. Than danger of development in the subsequent is more probable than the complications (infection, an arrangement near a large vessel etc.) connected with And. t., the more insistently indications to their removal, a cut it is desirable to make at surgical treatment of a wound (see. Wounds, wounds ). Secondary And. t., as well as. t., the containing toxic and radioactive materials, are subject to urgent removal.
In less urgent order it is necessary to take And. t., the supporting inflammatory processes, and also defiant pain, dysfunction and leading to development of other complications. It is necessary to delete everything from a bone tissue And. t., being in the bone cavity defined on the roentgenogram, and also supporting osteomiyelitichesky process. Metal fixers are taken after approach of consolidation of a change. In the remote period delete from a cavity of a joint And. t., causing dysfunction of a joint. Exact localization X-ray contrast And. t. establish radiological, it facilitates the subsequent extraction. Especially favorable conditions for removal X-ray contrast And. t. creates use of a mobile X-ray apparatus with the electron-optical converter (EOC) and the television screen. Great opportunities for exact definition of location And. t. and simplification of removal use of echolocation gives them. During removal ferriferous And. t. it is possible to use also special devices (see. Magnets medical , Electronic glockenspiel ).
To find dense And. t. at operation quite often it is possible, «having groped» it a syringe needle, but to the course a cut then make a section.
The needle or from tissue of a mammary gland sometimes manages to be removed from hypodermic cellulose without section. For this purpose it is necessary, taking fabrics pleated in one, in other direction, to grope at once both ends of a needle and by means of pressing to take it outside. For removal of the fishing hook which pierced in fabric small beards are deeper, it is necessary to take its edge outside and to break off nippers this or that end of a hook. After that the hook is freely taken out. In the presence of purulent fistula, especially alloyed, And. t. it can be sometimes removed through the fistular course by means of a styptic clip with thin branches. If it does not manage to be made, then make a section on the fistular course which is previously intensively painted over by means of introduction to it under pressure of colorant (e.g., solution of methylene blue). Superficially located splinters delete with an acute needle or do over a splinter a small notch a thin sharp-pointed scalpel.
Before removal And. t. it is necessary to enter antitetanic serum. Treatment of a postoperative wound is performed by the general surgical rules.
Basic distinction in surgical tactics during removal And. t. from soft tissues at children and at adults does not exist. However children shall have especially sparing surgical equipment, and x-ray radiation — minimum. Operations of removal And. t. shall be carried out in total with the actions directed to the prevention of development of infectious process (antibacterial therapy, etc.). The forecast after operation of removal And. t., as a rule, favorable, but substantially depends on location And. t. and the weight of an operative measure connected with it.
FOREIGN BODYS of the HEAD AND SPINAL CORD
And. t. get into a head or spinal cord at gunshot wounds, transport, home or production accidents. In the period of the Great Patriotic War the nonperforating getting wounds of a skull made 52,5% of all wounds of a skull (I. S. Babchin, 1949). Extra-and subdural localization And. t. in the vertebral channel made 8,3% of the operated wounded (D. G. Goldberg, I. Ya. Razdolsky, 1952). On materials of Scientific Research Institute of Emergency Medicine of N. V. Sklifosovsky (1962—1973), I. t. a brain were observed at 0,2% of victims with a craniocereberal injury, and at injuries of a backbone — at 3% of victims. Implementation And. t. is followed by disturbance of an integrity of soft tissues, bones, destruction of covers of a brain and marrow; there is a threat of formation of the shell or intracerebral hematomas, development liquorrheas (see), infectious complications (abscess of a brain, meningitis, encephalomeningitis or meningomyelitis, osteomyelitis) etc. Sometimes And. t. a brain are the reason of epilepsy. In some cases And. t. can be in a head cavity or the spinal channel, without injuring a brain.
Foreign bodys of a brain can be located in marrow in whole or in part, sometimes acting as one end in a wound. It can damage a venous sine, be located near it, in ventricles, get into other deep departments of a brain. The course of the wound channel can have various direction depending on changes of the movement I. t. at the time of wound (see. Craniocereberal injury ). At bullet or missile wounds And. t. sometimes makes a difficult way: from inlet opening it passes to the opposite side of a skull and a ricochet comes back again that can lead to the wrong conclusion about the tangential nature of wound. Large And. t. can sometimes migrate (fig. 5). Wedge, manifestations depend on localization And. t. in a brain, rate of decay of substance of a brain and degree of manifestation of infectious complications.
Diagnosis And. t. a brain the wedge is based on data of the anamnesis., rentgenol, and ekhoentsefalografichesky researches. Anamnestic data allow to establish character And. t., direction, sometimes and depth of its implementation. Nevrol. the research gives the chance to estimate severity of injury of a brain, to specify area of its wound. However at damage of «mute» zones focal symptoms can be absent, and the topical diagnosis can be established only by means of additional methods of a research. A crucial role in diagnosis And. t. plays rentgenol, the research allowing to specify number, localization, size and the nature And. t. and the nature of the accompanying bone damages. It is necessary to have roentgenograms at least in two mutually perpendicular projections. If according to such roentgenograms it is not possible to establish an arrangement And. t., resort to a multiaxial rentgenol, a research, tangential pictures or to a tomography. And. t., possessing small contrast (a tree, some grades of glass, plastic), sometimes it is possible to reveal only in aim tangential pictures. According to special indications for specification of the relation And. t. to brain structures make computer tomograms, an angiography of a brain or a pneumoencephalography.
For diagnosis of the intracraneal hemorrhages which are quite often accompanying And. t., it is used ekhoentsefalografiya (see). It allows to define not only localization And. t., but also distance from bones of a calvaria to And. t.
And. t. a brain are subject to removal soon after an injury when they are rather easily available and there is a primary type of the wound channel (V. N. Shamov, 1953). The absolute indication for the emergency surgical intervention, irrespective of localization And. t., formation of the shell or intracerebral hematoma is (only extreme weight of a condition of the patient can be a contraindication).
Large And. t., located close from bones of a calvaria, but far from inlet opening, delete through an additional trepanation opening in a projection And. t. Small in size metal And. t., which extraction is connected with great technical difficulties and danger of damage vitally or functionally important zones of a brain, is inexpedient to delete. In similar cases are limited to excision of inlet opening and partial processing of the wound channel.
And. t., the heads acting as one edge over soft tissues, other end can get into a venous sine therefore extraction And. t. for the acting part blindly it is inadmissible in order to avoid bleeding. It is necessary to make a resection of a bone around And. t., to open a firm meninx, to take And. t. and to be convinced of absence of bleeding and splinters in a wound. Removal And. t., being in substance of a brain, it is made during processing of a wound of a brain. From the wound channel by means of a suction and constant washing (fiziol, solution, hydrogen peroxide) wash a detritis and bone fragments, part the wound channel with pallets and it is careful, without sharp traction delete And. t. tweezers. Use of the shining tools as well as short-term increase in intracranial pressure by a prelum of jugular veins, promotes fuller removal of contents of the wound channel. Careful processing of the wound channel allows to refrain from its drainage. At impossibility of radical processing leave a drainage on 1 — 2 days. After removal And. t. in terms, early after wound, the firm meninx is not sewn up, the cranioplasty is not made. After an operative measure carry out the treatment directed to reduction of wet brain (see. Swelled also swelling of a brain ), maintenance of cardiovascular activity, prevention of infectious complications for what use massive doses of antibiotics.
Foreign bodys of a spinal cord can cause paralyzes, disorders of sensitivity and disturbance of functions of pelvic bodies. Careful nevrol, the research allows to determine the level of damage. Difficulties arise in diagnosis small And. t., especially when there is no rough injuries of a spinal cord. Use of multiaxial raying and Multiaxial X-ray analysis, use of reference points, mathematical calculations usually allow to specify character and localization And. t. (fig. 6). Specification of the diagnosis can be promoted by a likvorologichesky research (see. Liquorodynamic tests , Cerebrospinal liquid ), and at patients in satisfactory condition — miyelografiya (see).
Removal And. t. from a spinal cord presents considerable difficulties and demands the high surgical equipment, especially at partial injury of a spinal cord since there is a big danger of its additional destruction. In the postoperative period appoint dehydrational (see. Dehydrational therapy ) and antiinflammatory therapy to lay down. gymnastics, massage.
FOREIGN BODYS of an EYE
And. t. can be implemented into various departments of an eye. Depending on the place of implementation distinguish And. t. conjunctivas, corneas and And. t., located in an eyeglobe.
Foreign bodys of a conjunctiva
At hit And. t. on a conjunctiva they stick to it or are implemented into its fabric. Usually it are fine particles of the earth, a grain of sand, a particle of coal, a stone, metal. Hit And. t. on a conjunctiva causes the expressed irritation of an eye which is shown a photophobia nictitating spasm (see), pain, feeling of a foreign matter in an eye. At a research is defined And. t., lying on a conjunctiva or implemented into its fabric. Most often And. t. is located under an upper eyelid therefore it is necessary to twist an upper eyelid (fingers, it is possible by means of a glass rod) and to carefully examine a conjunctiva of an upper eyelid and a transitional fold.
Superficially located And. t. conjunctivas delete with the cotton plug moistened with disinfecting solution (2% boric to - that, solution of Rivanolum 1:1000, etc.). At implementation And. t. in fabric of a conjunctiva it is necessary to dig in a conjunctival sac 0,5% solution of Dicainum and to remove And. t. special needle or zhelobovaty dolotts. Then dig in in a conjunctival sac disinfecting solution (30% solution of a sulfacetamide of sodium, 0,25% solution of synthomycin, solution of Furacilin 1:5000) or put for eyelids 10% ointment of a sulfacetamide of sodium. Within 3 days it is recommended to continue to dig in any of the specified disinfecting drops.
Foreign bodys of a cornea
Foreign bodys of a cornea usually are located on its surface or are implemented into fabric on different depth. Deeply particles of metal are implemented into fabric of a cornea usually. The corneas which are in fabrics And. t. break an integrity of an epithelium, creating conditions for development of an infection (see. Keratitis ). After several hours of stay And. t. in fabric of a cornea around it the thin rim of infiltrate appears. Vessels of an eye react on And. t. pericorneal injection. The photophobia, dacryagogue, nictitating spasms, eye pains, feeling of «a grain of sand in an eye» is noted. At survey the conjunctival or mixed injection of an eye, presence of one or several is noted And. t. on a surface or in the thickness of a cornea. And. t., the corneas which are located in deep layers, can get one end into an anterior chamber.
The diagnosis usually does not cause difficulties; And. t. well considerably in the form of a brilliant or dark point. For definition of character and a depth it is necessary to use, except focal lighting by means of a magnifying glass, method of biomicroscopy (see. Biomicroscopy of an eye ).
And. t. corneas delete after a preliminary instillation in a conjunctival sac 0,5% of solution of Dicainum. And. t., lying on a surface of a cornea, take by means of the cotton plug moistened in 2% solution boric to - you. And. t., implemented into a cornea, delete with a special spear or a zhelobovaty dolotts.
Extraction And. t. from deep layers of a cornea make carefully because of threat of a perforation of a cornea or pushing through of a splinter in an anterior chamber.
Special difficulties are presented by removal of a splinter from back layers of a cornea if he partially acts in an anterior chamber. In such cases successful extraction And. t. perhaps only in the conditions of a hospital, sometimes after preliminary opening of an anterior chamber and introduction under a splinter of the pallet holding And. t. in a wound of a cornea. After removal And. t. apply a monocular sterile bandage for one day. During the next 3 — 5 days of the patient shall dig in in a conjunctival sac disinfecting drops (0,25% solution of synthomycin, solution of Rivanolum 1:5000, 30% solution of a sulfacetamide of sodium).
Intraocular foreign bodys
Constitute the greatest danger to an eye. They meet in 5 — 15% of all wounds of eyes. At the getting wounds of an eye intraocular And. t. are found in 45% of victims. During the Great Patriotic War intraocular And. t. at fighting injuries of an eye made 31%. Rather small part I. t. is late in a front half of an eye (an anterior chamber, an iris, a ciliary body, the back camera and a crystalline lens). Considerable part I. t. reaches back department of an eye (a vitreous, an idiovascular cover, a retina). At fighting injuries during the Great Patriotic War the small and smallest splinters (79% according to B. L. Polyak) which are not leading to considerable destruction of intraocular fabrics prevailed. Such magnetic And. t. during timely removal do not reduce a possibility of preservation of sight in a wounded eye.
Presence And. t. in an eye it is characterized first of all by existence of the getting inlet opening of various sizes and character in a cornea (thicket) or a sclera.
Sometimes inlet opening in a sclera does not come to light. It happens when the splinter, having passed through an upper or lower eyelid, is implemented into an eyeglobe through a sclera outside the part of an eyeglobe seen at inspection. At penetration into a cavity of an eye of big splinters the wound of a cornea or sclera has the considerable sizes, disappearance of an anterior chamber or massive hemorrhage in it is possible (see. Eye, damages ). At implementation And. t. through an iris the opening in it comes to light (a traumatic coloboma). At implementation And. t. through a pupil, as a rule, there is an injury of a crystalline lens.
At damage of a crystalline lens And. t. traumatic develops cataract (see). Damages of a crystalline lens can be various character: from its partial opacification to massive, sometimes with loss of lenticular masses in an anterior chamber. Development of a back bowl-shaped or rozetochny cataract can be observed.
The vitreous hemorrhage of various intensity more often happens at an injury of a ciliate body or a choroid. At implementation of a foreign body of the big sizes the gaping of a wound of a cornea or a sclera clinically decides on loss in a wound of covers of an eye — an iris, a ciliary body, an idiovascular cover, and also a vitreous, a crystalline lens and a retina.
Existence And. t. in an eye always causes response from tissues of an eye. A. L. Prigozhina allocated two types of reaction on And. t. At implementation large copper, brass, and also a plant origin And. t. there is exudative alterativnaya a reaction with formation of abscess around them. In the presence of small copper and brass And. t. in an eye there are no rough exudative reactions, and the released salts of copper gradually are laid in fabrics — develops halkoz eyes (see). Such changes are observed in all covers of an eye. At long stay in an eye chemically inert or not enough active And. t. (glass, aluminum, coal, particles of a stone) around them there is a productive reaction of histiocytic character which is coming to the end with formation of the capsule. And. t., containing iron, lead to emergence of a siderosis (see. Siderosis of an eye ). At the same time under the front capsule of a crystalline lens there are brown deposits, the iris becomes yellowy-brown color, dystrophy of a retina develops, changes in it remind a pigmental tapetoretinalny abiotrophy (see. Tapetoretinalnye dystrophies ). Capsule around And. t. does not protect, and only slows down development of adjournment in an eye of metal salts. As a result of dystrophic processes in a retina sight decreases.
For identification And. t. in an eye development of the system of the diagnostic actions pursuing the following aims is important: timely diagnosing And. t. in an eye, establishment of character And. t. (magnetic and its non-magnetic properties), its exact localization before operation (if necessary in addition define localization And. t. in the course of an operative measure).
For identification And. t. first of all it is necessary careful a wedge, inspection of the patient by means of focal covering, biomicroscopy, an oftalmoskopiya and other special methods of a research.
To establish existence And. t. the following signs help with an eye: 1) existence of the getting wound in a fibrous cover of an eye (a cornea, a limb, a sclera); 2) detection of the course of the wound channel in a cornea, an iris and a crystalline lens; 3) discrepancy between the size of a wound and visual acuity, considerable decrease in sight at small wound of an eye; 4) existence of air traps in a vitreous within the first days after wound; 5) deep anterior chamber and hypotonia of an eye; 6) development of an iritis or iridocyclitis.
Focal and biomicroscopic researches allow to reveal existence And. t. in a cornea, an anterior chamber, a crystalline lens, a vitreous. However the usual bio-microscopy not always allows to find a splinter in a corner of an anterior chamber. In this respect the method is of great importance gonioskopiya (see). For diagnosis And. t. the method of a research by means of an infrared slit lamp which gives the chance to see can be used And. t. in infrared beams.
From all rentgenol, methods of definition And. t. in an eye the most reliable and reliable is the method of a X-ray analysis. It should be applied in all cases of the getting injuries of an eye or at suspicion of the getting injury. And lack of a shadow on roentgenograms does not indicate absence And. t. in an eye.
For definition And. t. eyes it is necessary to make survey pictures of eye-sockets in two (and sometimes and three) mutually perpendicular projections: front (nosopodborodochny), side and axial. At the same time make aim pictures of the studied eye-socket with a narrow diaphragm in 25 mm. For definition And. t. eyes apply also a X-ray analysis with direct blowup that allows to reveal small metal and low contrast (porcelain, aluminum, glass) And. t., who on usual roentgenograms are visible seldom. If small or low contrast And. t. are located in front department of an eye, they can be found by means of a so-called technique of a besskeletny X-ray analysis. In cases of multiple missile wounds make a X-ray analysis of each eye-socket separately in a front projection irrespective of existence or absence a wedge, the data indicating injury of other eye.
In addition to establishment of existence And. t. in an eye-socket, it is necessary to establish the relation And. t. to an eye to define their form, the sizes, physical. characteristic and exact location. There is a large number rentgenol. methods of definition of location And. t. eyes which can be divided into the following groups: 1) physiological; 2) contact; 3) not contact.
I. Physiological methods. 1. Köhler's method — Golovina and his modifications. On one film make pictures of an eye in two of its various provisions (e.g., at a look up and from top to bottom). At stay And. t. in an eye (or its covers) on the roentgenogram two of its shadows are visible if And. t. it is located out of an eyeglobe, only one its shadow is visible. This method is very simple, but it not always allows to resolve an issue about out of - or an intraocular arrangement And. t. because at an arrangement of the last in a fascia of an eyeglobe (the tenonovy capsule), oculomotor muscles on the roentgenogram two of its shadows will be visible that shall indicate an intraocular arrangement And. t. Actually it will be out of an eye. 2. Goltsknekht's method in various modifications. The basis of these techniques consists in implementation of serial roentgenograms at certain shifts of an eyeglobe, on the Crimea define a rotation center of an eyeglobe and an otstoyaniye of shadows from a rotation center of an eye. Calculations of location And. t. by this method are difficult.
Besides, authors of many works proved that in an eye there is no uniform rotation center, and there are rotation centers of an eyeglobe for each plane. Therefore the data obtained by means of this method are insufficiently exact.
II. Contact methods, which essence is in what on the studied eye is imposed by identification tags (indicators).
1. Baltin's method — Komberg. After imposing approximately of a special prosthesis (Baltin's indicator) make a X-ray analysis in back, side and axial projections (fig. 7). By means of measuring templates of Baltin perfrom calculation of location And. t. (see. Baltina — Komberg a method ). Use of a prosthesis indicator is contraindicated in cases of extensive wounds of an eye and loss through a wound of its internal covers. The lack of a method is that all calculations are made on a schematic eye, the perednezadny size to-rogo is equal to 24 mm (whereas the sizes of an eyeglobe normal vary from 22 to 31 mm). Therefore at an arrangement And. t. in a so-called border area (at a cover of an eye) it is difficult to resolve an issue about inside - or its extra eye localization.
2. Abalikhin's method — Pivovarova. Do two roentgenograms: one in an axial projection, and the second — in side, using a prosthesis indicator, as in Baltin's technique — Komberg. Calculations are made by means of schemes measuring instruments. Shortcomings of a method same, as at Baltin's method — Komberg. 3. The Stereorentgenogrammetrichesky method of Weinstein — Urmakhera is based on the principles modern by a stereo-fotogrammetrii, providing high precision of space measurements. Situation and size I. t. in an eye calculate on the measured rentgenogrammetrichesky coordinates of the image of an indicator point (imposed approximately Baltin's pro-teza-indicator). These images receive by a simultaneous X-ray analysis of eye-sockets (fig. 8) on one film two X-ray tubes (or one X-ray tube from two points). Depth And. t. determine by the special table, previously having measured on a stereo pair distance between shadows of an indicator point and shadows And. t. Meridian of a bedding And. t. and its otstoyaniye from an anatomic axis is defined by the scheme measuring instrument. This method is convenient at a research of patients with multiple And. t. both (or one) eye-sockets and facial skeleton, when establishment of localization And. t. other techniques it is impossible. 4. The Besskeletny X-ray analysis according to Vogt. Rentgenol. researches of front department of an eyeglobe carry out by means of films the sizes of 30x60 mm which one end is found in the form of a shovel. Films turn at first in black, and then in wax paper. After their leading between the studied eye and the corresponding wall of an eye-socket make a X-ray analysis. In a picture the image of front department of an eye without bone imposings turns out. On such roentgenograms receive the image of the smallest and low-contrast And. t. For definition of location And. t. on besskeletny pictures make a X-ray analysis in two mutually perpendicular projections (side and axial). At the same time before a X-ray analysis impose an indicator point (fig. 9) on a limb (the place of transition of a cornea to a sclera). By means of schemes measuring instruments perfrom calculations of location And. t.
III. Not contact methods. 1. The X-ray anatomic method of Maykova — Stroganova consists in reconstruction of a sagittal axis of an eye and the plane of a limb in usual survey pictures of eye-sockets where the eyeglobe is projected on the corresponding bone points of an eye-socket and contours of soft tissues. Imposing measuring schemes on these reference points, define localization And. t. Using this method, it is possible to obtain sometimes wrong data because of the wrong laying of the head of the sick and projective distortion taking place at a X-ray analysis. 2. Not contact method of Weinstein. In a special tube the fixer of a look, the photographing device and indicators are built in. During a X-ray analysis coincidence of a visual axis of an eye and the central beam is provided. The photographic device allows to record the provision of an eyeglobe during execution of a picture and works synchronously with inclusion of high tension of a X-ray apparatus. On roentgenograms the image of indicators, a foreign body (fig. 10) turns out. Calculations of localization And. t. make by means of templates.
Use of this method is shown in cases of the extensive getting wounds of an eye, especially at loss through a wound of its internal covers, and also at children of younger age.
Ultrasonic diagnosis. Valuable diagnostic method And. t. in an eye the ultrasonic location is. The method of a one-dimensional ekhografiya (the domestic device «Ekho-oftalmograf») is generally used, at Krom the echo signals which are registered on the screen of an oscillograph can be photographed on photo or a film. By the form and to character of an echogram it is possible to define various patol, changes in an eye, including and existence in it And. t.
Diagnostic electrolocation. For definition And. t. in an eye it is possible to use the method of an electrolocation based on change of inductance of the coil of a contour of the generator at hit in its field of a metal subject. Emergence of sound or light signals of the device demonstrates existence in an eye metal And. t. For the purpose of definition of magnetic properties of a splinter quite often apply so-called magnetic test on the shift of a splinter, to-ruyu make at biomicroscopic survey as at localization And. t. in front department of an eye, and in a vitreous and on an eyeground at oftalmoskopichesky survey.
Test is made by means of a manual electric magnet of average power. Bring closer a magnet to a cornea, switch on and off current; at correctly and carefully taken samples magnetic And. t. slightly turns towards a magnet. Geylikman's test is more sparing: the head of the patient is placed in the solenoid of a big electromagnet. At inclusion and switching off of current And. t., having magnetic properties, begins to fluctuate.
During removal And. t. from an anterior chamber of an eye two main methods can be used: the arc-shaped section of a cornea a cataract knife on Gaab's way and outside approach through area of a corner of an anterior chamber according to Gayet. Use Gayet's way more often.
Before operation for the maximum narrowing of a pupil by the patient dig in 4% solution of Pilocarpinum. At adult patients operation is made under local anesthesia, at children — under anesthetic.
According to localization And. t., otstupya from a limb on 5 — 6 mm, make a section of a conjunctiva, edges it otseparovyvatsya to a limb. Apply a section of a sclera, otstupya on 2 mm from a limb, and the sclera in the form of a visor on 1/3 its thickness otseparovyvatsya to a limb. Then impose 2 — 3 provisional sclero-scleral seams. After suture between them make opening of an anterior chamber and expand a section with corneal scissors a little. The section is done a little big, than size I. t., taking into account a possibility of removal And. t. tweezers. Under a corneal and scleral rag bring a magnet, and And. t. delete. If. t. it is not possible to remove with a magnet, it is taken tweezers, sometimes with excision of a radical part of an iris. After extraction And. t. tie sclero-scleral seams, put a continuous suture on a conjunctiva.
In the presence of magnetic And. t. in the back camera it is possible to make attempt a magnet to transfer it through a pupil to an anterior chamber. However if. t. has irregular shape with the pointed corners, such manipulations can cause an injury of the capsule of a crystalline lens with the subsequent development of a cataract. In this regard at a transparent crystalline lens it is better to make in the place of localization And. t. corectomy (see), and then to bring him out of an eye a magnet through an educated coloboma of an iris.
Removal And. t. from a transparent crystalline lens — very complex challenge since the wrong technique of extraction of a splinter involves bystry development of a traumatic cataract.
In the presence of magnetic And. t. in a transparent crystalline lens it is recommended by a magnet to remove via the wound channel of a crystalline lens And. t. in an anterior chamber, and then after opening of an anterior chamber to remove it from an eye. If. t. under the influence of magnetic draft does not cut the front capsule of a crystalline lens, it is necessary to make in the capsule very small cut a knife Gref or a special spear of a design of Morozov.
Removal And. t. from a ciliate body and a vitreous it is, as a rule, made diaskleralno (see. Diaskleralny operations ). The essence of a diaskleralny method consists in that, as. t., located in a ciliary body and back department of an eye, inspections are taken through the section in a sclera made according to data rentgenol, i.e. it is the closest to the place of a bedding And. t. Before removal And. t. put scleral stitches, without tightening them. Bring a tip of a magnet to a wound and after removal And. t. the scleral seam is tied.
The patient, the Crimea it was already undertaken earlier one or several unsuccessful attempts to take And. t. or when And. t. it is encapsulated, it is recommended to make - or a P-shaped section of a sclera with preliminary imposing of scleral seams. If. t. it is not possible to take a magnet, it should be deleted, as well as nonmagnetic, tweezers or the cryoapplicator (see. Cryosurgery, devices ).
Removal And. t. from covers of back department of an eye (20 — 22 mm from the plane of a limb) presents great difficulties. In such cases it is necessary to try to transfer it a magnet to area of the gear line of a retina and to take diaskleralno. If. t. it is not possible to transfer to the gear line, it is deleted diaskleralno in the place of localization with preliminary crossing for convenience of operation of one or two direct muscles, with their podshivaniye on the former place after removal And. t.
Considerable difficulties are presented by removal from an eye nonmagnetic And. t. From an anterior chamber they are removed by Gayet's technique described above special tweezers or gripping holders. Removal nonmagnetic And. t. from a crystalline lens it is made already at a considerable phacoscotasmus therefore it is taken together with a crystalline lens.
At diaskleralny operation of removal of nonmagnetic splinters from a ciliary body use - or a P-shaped section of a sclera to a choroid with preliminary imposing on a wound of a sclera of two or more silk seams. After stratifying of a ciliary body the pallet I. t. take tweezers.
During removal nonmagnetic And. t. from a vitreous in the place of a projection And. t. on a sclera do the G-shaped or P-shaped section of a sclera on which previously impose silk seams, without tying them. In a zone of a section make diathermocoagulation of a sclera for the purpose of prevention of postoperative amotio of a retina. Then the idiovascular cover is carefully stratified the pallet and with special tweezers or the gripping holder deleted And. t. After that tie scleral seams and put a continuous suture on a conjunctiva.
For extraction non-magnetic intraocular And. t. often use the electron-optical converter, with the help to-rogo it is possible to receive rather contrast enlarged image during operation And. t. and under control of sight to take it, minimum injuring an eye.
At any getting wound of an eye and which is especially followed by implementation in his cavity And. t., it is necessary to hold preventive events for protection from development of an infection in an eye that can bring to to an iridocyclitis (see), to a panophthalmia (see), to an entophthalmia (see). For this purpose under a conjunctiva within 4 — 5 days enter antibiotics in combination with their intramuscular introduction.
FOREIGN BODYS of the EAR
And. t. fish soup can be organic (peas, haricot, stones of fruits) and an inorganic origin (metal balls, fine details of toys). They are found more often in children who put them at games. Meet also live And. t. — flies, mosquitoes, small bugs.
And. t. are late in initial department of acoustical pass more often, but can get to its bone part. Big And. t., completely corking a gleam of outside acoustical pass, reduce hearing, hurt, cause the reflex cough reminding asthmatic, nausea, vomiting. Especially unpleasant, painful feelings are caused live And. t. Sometimes And. t. can be a long time in outside acoustical pass asymptomatically, but cause outside or average otitis more often. Quite often they are found at routine maintenance, otoskopiya (see). The diagnosis is facilitated by production of roentgenograms in typical projections according to Maier, Schueller and Stenvers (see. Middle ear, Radioanatomy ). To differentiate And. t. fish soup it is necessary with tumors and exostoses of outside acoustical pass.
Not inflating And. t. delete by ear irrigation from the syringe with a capacity of 100 — 150 ml with a water jet with addition of disinfecting solutions: Furacilin, weak solutions of potassium permanganate (see. Ear irrigation ). At inflating And. t. (peas, haricot) for reduction of their sizes previously dig in in an ear 70% alcohol, and then wash away water or delete with a hook. Pieces of paper, a slate pencil of a chemical pencil are taken a hook. Live And. t. destroy, digging in sterile oil (vaseline, sunflower, camphoric), and then wash away them. It is not necessary to delete And. t. rounded shape from outside acoustical pass by tweezers since perhaps pushing through is farther than it. At impossibility to take And. t. from outside acoustical pass resort to surgical intervention. Under local anesthesia of 0,5% solution of novocaine or under anesthetic do a section parallel to an attachment of an auricle, otseparovyvat soft tissues together with outside acoustical pass, cut the last and And. t. take. In inept attempts to remove And. t. from outside acoustical pass it can get into a drum cavity. In such cases most of patients has an acute inflammation of a middle ear. Also heavier complications are observed: labyrinthitis (see), meningitis (see. Meningitis, otogenic, rhinogenic ). To delete And. t. from a drum cavity it is necessary in a hospital under anesthetic, a hook. After removal And. t. enter a sterile turunda into outside acoustical pass. Observation and purpose of antiinflammatory therapy is necessary. It is not recommended to dig in drops in an ear.
FOREIGN BODYS of the NOSE
And. t. a nasal cavity occur preferential at children. They are very various on character, a form, size (seeds of plants, pieces of vegetables, papers, buttons, balls, pins, small screws, etc.). More often they are localized in the closing nasal stroke. In most cases children put And. t. in Nov to either, or the companions during the game. Seldom And. t. gets to a nasal cavity at vomiting through a postnaris. And. t. in a nose cause reflex sneezing, dacryagogue, the complicated nasal breath. At long stay And. t. in a nose there are purulent, sanious discharges, is frequent with a putrefactive smell, usually defined in one half of a nose, but at hit And. t. in both half of a nose of allocation happen bilateral. Sometimes And. t. become covered with limy, phosphate salts and form rhinoliths (see). Diagnosis And. t. nasal cavities sometimes presents great difficulties. It is necessary to apply front and back rinoskopiya (see). X-ray contrast And. t. a nasal cavity and his adnexal cavities define by roentgenoscopy and a X-ray analysis in frontonasal, nosopodborodochny and side projections (fig. 11 and 12). Small low-contrast And. t. soft tissues and cartilages of a nose come to light in contact screenless pictures. Sometimes for detection small and contrast And. t. adnexal nasal cavities, except usual roentgenograms, apply a tomography and contrasting of okolonosovy cavities (see. Gaymorografiya ). To differentiate And. t. it is necessary for a nasal cavity with tumors, diphtheria, a disease adnexal bosoms of a nose (see). It is long being in a nasal cavity And. t. delete by means of hooks, nippers under local anesthesia (2 — 3% solution of cocaine) or under anesthetic with a preliminary instillation in Nov of vasoconstrictors (2 — 3% of solution of ephedrine, etc.) - In attempt to remove And. t. from a nasal cavity tweezers it is possible to advance it more deeply, and it at breath can get into a throat, a trachea and bronchial tubes. The most frequent complication at And. t. nasal cavities — a disease of okolonosovy bosoms. Therefore after removal And. t. control is necessary medical and rentgenol.
FOREIGN BODYS of the THROAT AND GULLET
And. t. drinks and a gullet meet quite often. More often it is bones, especially fish.
Foreign bodys of a throat
In a drink And. t. most often get stuck in almonds, is more rare in a mucous membrane of a back wall of a throat, in a nasal and guttural part of a throat (fig. 13). Patients complain of pain during the swallowing, hypersalivation, twang, difficulty of swallowing, and sometimes and breath. At long stay And. t. in a drink in surrounding fabrics inflammatory process which complicates diagnosis and treatment develops. And. t. drinks are found at survey of a throat, a nasal part of a throat (a back rinoskopiya), a laryngopharynx (an indirect or direct laringoskopiya).
And. t. drinks delete under local anesthesia (greasing of a mucous membrane of a throat of 2 — 3% solution of cocaine), sometimes under anesthetic. For extraction And. t. use Gartmann's nippers or tweezers (see. Otorhinolaryngological tools ). During removal And. t. from a laryngopharynx apply special nippers. After removal And. t., it is long being in a drink, medical observation, purpose of antiinflammatory therapy is necessary.
Foreign bodys of a gullet
In a gullet get stuck And. t. the most various character (bone, buttons, dentures and t. p). At elderly people obturation of a gullet is sometimes observed by pieces of badly chewed meat. Quite often in a gullet several pieces of meat which owing to a hyperperistalsis soon as if are stamped and gather in one big lump consistently get stuck. Multiple And. t. can be a consequence of attempts to push available And. t. by a proglatyvaniye of pieces of meat or crusts of bread.
The most often acute And. t. (preferential bones) get stuck in a cervical part of a gullet and is much more rare in chest according to places fiziol, esophageal stenoses. Large stupid And. t., napr, coins, get stuck in a chest part (fig. 14) more often; in the same place there is obturation of a gullet badly chewed dense food. If. t. have big length, their one end can be in a gullet, and to rest the second against a wall of a stomach in the field of big curvature. Often And. t. a gullet are observed at the persons suffering from its partial narrowing after the postponed burn of a gullet. Occasionally And. t. can be in a gullet very long and cause cicatricial changes of its (fig. 15) that is the reason of operation. Rather long And. t., not causing a full dysphagy, can be in a gullet at small children.
Signs of existence And. t. happen primary (caused And. t.) and secondary (the caused complications). At smooth And. t. patients originally note feeling of jamming of the swallowed subject in a gullet, pressure and constraint in a breast. The subsequent drinks do not give relief, the stethalgia connected with development of an esophagism soon joins. Appears dysphagy (see), expressiveness the cut depends on engagement factor of a gleam of a gullet And. t. Flat objects (a coin, a button) can not cause dysphagies. At full obturation of a gullet there is a vomiting (so-called esophageal vomiting) the liquid and food accumulating over the place of obturation. Vomiting gives temporary relief. At long obturation the progressing dehydration of an organism develops. At acute And. t. the main symptom is the pain which is becoming aggravated during the swallowing. Pain is most often localized in a neck and an upper part of a thorax, irradiates in interscapular space and not always strictly corresponds to the level of an arrangement And. t. Similar symptoms arise and can remain within 1 — 2 days also during the drawing scratch in a gullet acute And. t., independently fallen to a stomach, than that circumstance that at a number of the patients addressing with complaints to jamming in a gullet also speaks And. t., it is not possible to find the last. Are most dangerous And. t. a gullet at children. Small children become very uneasy. The senior children usually localize pain in the area corresponding to stay And. t.
One of the symptoms indicating existence And. t. in a gullet children of the first months and years of life, can have a disorder of breath. This results from the fact that And. t., got stuck in a gullet at the level of the first fiziol, narrowing, squeezes a throat, causing its hypostasis which complicates breath owing to what children sometimes shower a head back.
G. Killian distinguished from secondary symptoms and described the triad characteristic of damage of cervical department of a gullet: 1) the progressing increase of independent pain and morbidity at a palpation of a neck; 2) emergence of inflammatory infiltrate on a neck; 3) fervescence.
And. t. a gullet can lead to development of heavy complications: perforation of a gullet acute And. t. with development of a purulent mediastinitis; decubitus of a wall of a gullet which can develop within several days with development of a mediastinitis, pleurisy, a pericardis or uzura of a large vessel with fatal bleeding; full impassability of a gullet owing to its obturation.
At perforation or decubitus of a chest part of a gullet morbidity and inflammatory infiltrate on a neck are absent. In these cases great diagnostic value has emergence of hypodermic emphysema on a neck, edges is shown by crepitation at a palpation; she is visible on the roentgenogram, and at survey it is found as a peculiar swelling without inflammatory reaction. At the same time symptoms begin to develop mediastinitis (see) with the accruing intoxication.
Diagnosis And. t. a gullet is based on data of the anamnesis or on assessment listed above a wedge, symptoms. The final stage of diagnosis is ezofagoskopiya (see), rentgenol, researches.
Radiodiagnosis of foreign bodys of a gullet and throat
Contrast And. t. and a gullet it is easy to find drinks at raying and on roentgenograms in direct and side projections. Large And. t. usually are late in a gullet at the level of it fiziol, narrowings, at the same time, unlike And. t. throats and tracheas, the frontal arrangement flat is characteristic And. t. (coins, buttons, etc.). For diagnosis low contrast And. t. chest department of a gullet use Ivanova-Podobed's method: during raying to investigated suggest to swallow one teaspoon of a baric suspension of a consistence of dense sour cream, and then to wash down it with several drinks of water. At the same time barium accumulates on And. t. also it is long does not wash off, forming the resistant contrast spot corresponding to localization And.
of this year M. Zemtsov offered for diagnosis And. t. drinks and an upper part of a gullet to use a non-contrast telex-ray analysis of a neck in a side projection at the time of breath holding. At the same time the picture with accurate X-ray anatomical structure of a throat, throat and soft tissues of a neck turns out, on Krom shadows of small fish stones and others low-contrast can be visible And. t. in a throat, a throat and a cervical part of a gullet.
Use of a method of Wilson is in certain cases shown: the victim swallows the wadded lump impregnated with a baric suspension that gives the chance to define localization And. t. gullet (stop of a wadded lump).
Except identification And. t. and establishments of its localization, rentgenol, the research helps to diagnose various complications caused as stay And. t. in a gullet, and surgical interventions apropos And. t. At obturation of a gullet And. t. a contrast agent is late over it, determining the level and degree of impassability of a gullet.
At development of an esophagitis emergence of a strip of gas in a gleam of a gullet can be observed above And. t. owing to inflammatory infiltration of a wall, and also insufficiently full washing off of a baric suspension from folds of a gullet because of inflammatory hypostasis of a mucous membrane. It is quite often possible to see expansion and consolidation of a shadow of peripharyngeal or periesophagal cellulose of a neck, and in some cases to find in it vials of gas and a horizontal fluid level (in the presence of abscess).
Direct symptom of a rupture of a wall of a gullet or throat is flowing of a contrast agent for their contours. The contrast research allows to establish a rupture of a wall of a gullet, its place and the sizes. At an injury of chest department of a gullet it is possible to see expansion and consolidation of a shadow of a mediastinum or his emphysema.
Removal of foreign bodys of a gullet
Danger of development of terrible complications demands the emergency removal And. t. a gullet, a cut carry out by means of the tubular esophagoscope or a fibroezofagoskop (see. Bronkhoezofagoskop ). Fibroezofagoskop is convenient for diagnosis And. t. a gullet, but with its help it is possible to take only small And. t. Deletes And. t. a gullet the surgeon, the otorhinolaryngologist or the endoscopist in to lay down. the establishment having surgical department in Krom the immediate surgery (including and transpleural), necessary in case of perforation of a gullet can be made. Manipulations blindly with a packer, a monetolovka and other similar tools are inadmissible, T. K. at the same time are possible serious complications. To delete And. t. from a gullet it is possible under a local anesthesia, however in unfortunate attempt of such extraction it is necessary, having temporarily stopped manipulation, to pass to an anesthesia with introduction of muscle relaxants and an intubation of a trachea (see. Intubation ). Full relaxation of skeletal muscles, and also cross-striped muscles of a throat and an upper third of a gullet facilitates manipulations on extraction And. t. also reduces danger of perforation to a minimum. At rather large And. t., at obturation of a gullet badly chewed food, and also at children, easily excitable patients and at mentally sick an ezofagoskopiya need to be made under anesthetic, without resorting to local anesthesia.
Rather small And. t. (e.g., pins) delete under control of sight through a tube of the esophagoscope, resorting also to turn I. t. in various directions (fig. 16, and and b). A set of hoes (nippers) which cover is applied to the Bryuningsa esophagoscope And. t. fenestrated shutters, capture them dense branches or acute teeth, and also hook tubular And. t. from within. Large And. t. delete with hoes, also the tube of the esophagoscope at the same time is removed. In some cases at impossibility to remove And. t. in the oral direction it (under control of sight!) hoes carefully reduce in a stomach (fig. 16, c). However pushing through in a stomach occlusive a gullet of lumps of not chewed food inadmissibly since quite often the gullet distalny obturation is patholologically changed (a tumor, cicatricial narrowing).
After extraction And. t. and cancellation of local anesthesia or an anesthesia by the patient according to indications make a control contrast X-ray analysis of a gullet for the purpose of identification of signs of possible perforation.
At detection of a fresh rupture of a gullet make an immediate surgery (see. Gullet, operations ).
FOREIGN BODYS of the THROAT, TRACHEA AND BRONCHIAL TUBES
In a throat, a trachea and bronchial tubes And. t. most often get from an oral cavity, is much more rare And. t. get into airways as a result of wound. Most often And. t. throats, a trachea and bronchial tubes are observed at children up to 5 years which are accustomed to hold various objects in a mouth (coins, small toys, peas, etc.). Often fish bones, stones of fruits get into airways.
Mechanism of hit And. t. in respiratory tracts it is constant: an unexpected deep breath (at a fright, laughter, crying) in the time spent of a foreign subject in a mouth.
The diseases which are followed by fits of coughing (whooping cough, bronchial asthma) promote hit And. t. in respiratory tracts.
And. t. can get into airways during intoxication, as a result of weakening of a tussive reflex.
Existence of a valve mechanism of the tracheobronchial tree which is that at a breath bronchial tubes extend, and at an exhalation are narrowed, disturbs a vykashlivaniye And. t. Owing to negative pressure in lungs at a breath they get into small bronchial tubes.
Foreign bodys of a throat always cause pristupoobrazny reflex cough. During the fixing
And. t. between voice folds hoarseness up to an aphonia is often observed. It is long being in a throat And. t. lead to a reactive inflammation of surrounding fabrics, a cut creates an obstacle for breath. Patients can have symptoms of respiratory insufficiency: inflating of wings of a nose, retraction of intercostal spaces, over - and subclavial poles at a breath, cyanosis of skin and visible mucous membranes. Large And. t. can give throats to asphyxia (see).
The diagnosis is made on the basis of the anamnesis, a wedge, symptoms, survey of a throat at direct or the return laringoskopiya (see); at percussion of lungs the tympanites is defined, at auscultation — the weakened breath.
At rentgenol. research large metal And. t. (coins, badges, buttons, etc.) often are found in a throat at the level of a glottis. On side roentgenograms of a neck And. t. are well visible in front departments against the background of air in a gleam of a throat. In a direct picture round flat metal And. t. (coins, buttons) are located longwise in the sagittal plane according to position of a glottis, unlike And. t. a gullet which, as a rule, at this level are located in the frontal plane.
And. t. throats need to be differentiated with diphtheria of a throat, subchordal laryngitis, a spasmophilia, an asthmatic bronchitis, whooping cough, a tumor, internal cysts of a throat, tuberculosis, syphilis of a throat, etc. Treatment depends on the general condition of the patient, degree of a stenosis of a throat (see. Laryngostenosis ). At the compensated or subcompensated stenosis of a throat And. t. delete in specialized department. At a dekompensirovanny stage of a stenosis of a throat or asphyxia previously it is necessary to resort to urgent tracheotomy (see), and then to take And. t. Delete And. t. throats by means of a direct laringoskopiya under local anesthesia at adults and under a short-term anesthesia at very uneasy children. And. t. take nippers, quiet rotary motions release from surrounding fabrics and take. Sometimes owing to shift And. t. during its removal there can come sudden asphyxia therefore the doctor shall be ready to urgent tracheotomy. If. t. it is not distinguished, hypostasis of soft tissues, a perichondritis of cartilages of a throat with the subsequent stenosis of a throat can develop further.
Foreign bodys of a trachea are most often observed at children (43% aged from 2 up to 4 years, according to I. I. Shcherbatov, 1970). Small And. t. (seeds of a water-melon, sunflower, etc.) easily slip with an air flow through a glottis. Large And. t. with a pulled surface or keen edges are fixed in a trachea, but is more often And. t. «ballot» in a trachea. The general condition of patients, at which And. t. it is fixed in a trachea, heavy. Disturbance of breath is sharply expressed. Under the influence of irritation of sensitive receptors of a mucous membrane of a trachea And. t. there is an attack of reflex cough with expectoration, sometimes with impurity of blood, often cough is followed by vomiting. In certain cases, when And. t. not completely closes a gleam of a trachea, during a breath it is possible to hear the whistle similar to that which is observed at patients bronchial asthma (see).
Diagnosis And. t. tracheas put on the basis of the anamnesis, a wedge, data and rentgenol, researches. To differentiate And. t. respiratory tracts it is necessary with whooping cough, an asthmatic bronchitis, bronchial asthma, bronchitis, tumors. To delete fixed And. t. it is the most convenient than a trachea by means of the bronchoscope, during removal balloting And. t. the direct laringoskopiya is necessary.
Foreign bodys of bronchial tubes are usually aspirated by children. The most often aspirirovanny And. t. are localized in the right primary bronchus (62 — 70,2%), is more rare in left (29 — 38%) that is connected with anatomo-fiziol, features of a structure of a tracheobronchial tree: the right primary bronchus wider and is as if continuation of a trachea. Wedge, symptoms And. t. bronchial tubes are various and depend on the size and a form I. t., localizations, duration of their stay there. Vykashlivaniye I. of t. from bronchial tubes it is observed seldom. Large And. t. are late in the main bronchial tubes, small get into lobar and segmental bronchi.
If. t. completely closes a gleam of a primary bronchus, from breath one lung is switched off at once that leads to development of expressed respiratory insufficiency (see). At survey of the patient lag of an excursion of a half of a thorax is noted, at percussion — obtusion of a pulmonary sound, at auscultation — weakening of breath up to its absence. Sometimes And. t. can get at the same time both in right, and to the left primary bronchus. Condition of patients at the same time very heavy. The wedge, symptoms of acute respiratory insufficiency are sharply expressed. At hit small And. t. in lobar bronchi at most of patients satisfactory condition, breath free, dry, rare, but constant, sometimes pristupoobrazny cough remains. Perkutorno is defined shortening of a pulmonary sound over the site of a lung corresponding to a bronchial tube, in Krom is And. t. Auskultativno is listened the weakened breath, sometimes dry rattles in the same place. Big danger is constituted multiple And. t. bronchial tubes: pieces of nuts, carrots, grain, etc. Being fixed in small bronchial tubes, they quickly cause development of pneumonia, for a cut the fact that it develops without the previous inflammatory changes from upper respiratory tracts is characteristic. Pneumonia has recurrent character, will badly respond to treatment by the standard methods. Pneumonia always in the same lung where is recurs And. t. Pneumonia often is complicated by a share or segmented atelectasis.
At hit And. t. in respiratory tracts small children, as a rule, have no anamnestic data since aspiration And. t. often passes unnoticed. Sometimes at patients slightly complicated breath is noted. Frequent diseases of bronkhopulmonalny system at children (a tracheobronchitis, bronchial pneumonia, whooping cough, etc.) sometimes lead to the fact that the doctor does not suspect about a possibility of aspiration And. t. The brightest symptom is vomiting, sometimes repeated that forces to assume «proglatyvaniye» And. t., but not its aspiration. Bystry development of inflammatory process in bronchial tubes and lungs is observed. From the moment of aspiration And. t. before emergence of complications, especially at aspiration organic And. t., there passes small term — from several hours to 1 — 2 days.
Detection and localization contrast And. t. bronchial tubes are carried out by means of multiaxial raying and pictures in a straight line and side projections (fig. 17 — 20). Knowing a radioanatomy of segments of lungs and a bronchial tree, it is easy to establish a segment, in Krom is And. t. Radiodiagnosis low-contrast And. t. bronchial tubes it is based on identification morfol, and functional changes in lungs which depend on extent of obstruction of a gleam of a bronchial tube And. t.
At partial bronchial obstruction, when diameter And. t. it is less than diameter of gleam of a bronchial tube, ventilation of the respective site (a share, a segment) a lung is lowered. At rentgenol. a research the shift of a shadow of a mediastinum is noted during a deep breath towards damage of a bronchial tube (see. Goltsknekhta-Jacobson symptom ), lag of respiratory movements of a diaphragm, and also decrease in transparency of the pulmonary field on the party of defeat.
At valve bronchial obstruction rentgenol, the research reveals unilateral emphysema (fig. 21), expansion of intercostal spaces, flattening of a dome of a diaphragm, restriction of its mobility on the party of bronchial obstruction. The median shadow is displaced in the opposite healthy side that is especially noticeable at a sharp exhalation. Emphysema at valve bronchial obstruction is characteristic the fact that the lung remains expanded as at a breath, and an exhalation.
At full bronchial obstruction homogeneous blackout of a segment or a lung lobe is defined. At large And. t., fixed in the mouth of a primary bronchus, there can be a total atelectasis of all lung.
At suspicion on And. t. a bronchial tube if this raying and a X-ray analysis is insufficiently convincing, it is necessary to apply tomography (see) and bronchography (see) since they allow to find a shadow And. t., to track width of a gleam and passability of a bronchial tube.
Removal And. t. bronchial tubes — usually urgent action. Apply upper to this purpose bronkhoskopiya (see). In the presence of the respiratory bronchoscope removal And. t. carry out under anesthetic. It is also possible to take And. t. from bronchial tubes at artificial ventilation of the lungs by an injection method when during the giving air-narcotic mix sealing of the bronchoscope is not necessary. Metal And. t. it is less traumatic to delete at a bronkhoskopiya by means of a permanent magnet or an electromagnet (see. Magnets medical ). Contrast And. t. irregular shape it is possible to delete under control of the x-ray screen. And. t., which are not possible for removing at an upper bronkhoskopiya, sometimes it is possible to remove at the lower bronkhoskopiya.
To find and remove And. t. presents considerable difficulties since over them often there is an edematous inflammatory roller of a mucous membrane. Bronkhoskopiya quite often it is necessary to repeat. Before a bronkhoskopiya for removal of a tussive reflex the mucous membrane of a throat is anesthetized by 2 — 3% solution of cocaine or xylocainum. Further, depending on a situation, also Muscle relaxants can be used.
During removal And. t. from respiratory tracts there can be following complications: connected with insufficient preparation of tools and patients (aspiration of emetic masses, a cardiac standstill and breath); with the wrong selection and failure of tools (leaving in respiratory tracts of tips, lumps of cotton wool); connected with extraction acute And. t. (perforation of a bronchial tube, emphysema hypodermic and mediastinums, bleedings). Quantity of complications during removal And. t. sharply decreased using a subnarcotic bronkhoskopiya.
FOREIGN BODYS of a throat and upper respiratory tracts, first aid and resuscitation
(From additional materials)
And. t. drinks and upper respiratory tracts often lead to asphyxia (see), to bystry development of a terminal state (see) and even by death if injured help is immediately not given. In this regard the actions directed to the fastest removal And. t. upper respiratory tracts, it is possible to carry to resuscitation (see Resuscitation) in spite of the fact that resort to them even at satisfactory cordial activity and the kept consciousness at the victim. Completely the gleam of respiratory tracts is closed large And. t., but the possibility of asphyxia is not excluded and at hit in them small And. t., a small amount of water or food masses owing to a reflex laringo-or a bronchospasm.
The most frequent reason of hit And. t. in upper respiratory tracts their aspiration from an oral cavity is. Normal it is interfered by two protective mechanisms: reflex closing with an epiglottis of an entrance to a glottis during the swallowing of food and the cough (see) arising also reflex if the first mechanism is insufficient. Aspiration And. t. can occur if the person, talking during food, in the presence of food in a mouth, especially firm and small cut (e.g., pieces of meat), takes the bystry forced breath for continuation of a conversation. At
Fig. 1. Receptions of a self-care at aspiration of a foreign body: and — tolchkoobrazny pressing by both hands on an upper part of a stomach; — a bystry inclination of a trunk forward with an emphasis an upper part of a stomach on a back of a chair.
it the protective movement of an epiglottis is late. Aspiration is even more probable And. t. because of oppression of a gag reflex at defeats of c. N of page, overdose of hypnagogues and tranquilizers, poisonings and comas, drowning, etc.
In some cases reflex the arising cough leads to evacuation And. t. from upper respiratory tracts. That it was effective, the victim shall inhale and begin previously deeply an exhalation at the closed glottis; pressure in respiratory tracts at the same time sharply increases and at the time of opening of a glottis the current of air going from lungs pushes out And. t. If. t. is located in a glottis or subcopular space, the preliminary deep breath is impossible. In such cases cough -
the Vyya pushes make at the expense of the air which remained in lungs after the easy not forced breath. The victim at the same time shall not talk, call to the aid, try to make a deep breath.
As measures of a self-care use also following methods. The victim both hands abrupt pushes presses on epigastric area (fig. 1, a). At other reception the victim quickly bends forward, rests a stomach against a back of a chair (fig. 1, b) is also outweighed through it. The supertension which is created in an abdominal cavity during the performance of both receptions is transmitted through a diaphragm on a chest cavity that promotes pushing out And. t. from upper respiratory tracts.
If the self-care for any reasons is impossible or does not give desirable effect, help by other person by consecutive carrying out two receptions shall be given to the victim. Giving help approaches the victim behind and puts with a proximal part of a palm 3 — 4 abrupt blows in a backbone at the level of the upper edge of shovels (fig. 2, a). If it does not lead to pushing out And. t., giving help, continuing to stand behind the victim, covers it both hands, places a fist of one hand on epigastric area of the victim, covers with a palm of the second hand a fist and 3 — 4 times press the victim to themselves, making abrupt pushes in the direction in front back and from below up (fig. 2, b).
If the victim fainted and the respiratory movements at it are absent, giving help begins an artificial respiration from a mouth in a mouth (see. Artificial respiration). If at the same time the thorax does not extend, it is necessary to assume that the apnoea is caused And. t. For assistance kneel sideways from the victim lying on spin turn it sideways, facing themselves; having taken by hand of the victim and holding it one hand in such situation, put with a proximal part of a palm of the second hand 3 — 4 abrupt blows in his back between shovels (fig. 2, c). Again turn the victim on a back, a palm of one hand put on his epigastric area, and a palm another — on a dorsum of the first; both hands 3 — 4 times sharply press on epigastric area in the direction in front back and from below up (fig. 2, d). Then open for the victim a mouth and a finger take dropped out of respiratory tracts
of Fig. 2. Methods of first aid to the victim who is in consciousness (oh) and unconscious (in, d) at aspiration of a foreign body: and, in — drawing abrupt blows by a proximal part of a palm on interscapular area of the victim; — tolchkoobrazny pressing by both hands on an upper part of a stomach of the victim in the direction in front back and from below up.
II. t. After that continue to hold an artificial respiration and other resuscitation events.
twisting of resistance to the subsequent virusnokhm to infection. And. have universal antiviral activity, however in-terferonobuslovlenny protection of cells against separate viruses differs in different degree of manifestation. Efficiency And. it is most intensively shown in gokhmolo-gichny cells, i.e. in cells of that species of animals, from to-rykh drugs I were received. (specific specificity of action). And. it is possible to consider as a factor of nonspecific resistance of an organism (see) and as the factor possessing regulatory impact on immune system of an organism (see Immunity). And. has antineoplastic effect. The items which are formed in leukocytes or fibroblasts in response to influence of viruses or synthetic polyribonucleotides (see Inductors of interferon). are carried to interferon I of type or respectively to leukocytic and
At bessoznatelnokhm a condition of the victim and impossibility to remove And. t. in the ways described above in the conditions of medical establishment it is necessary to make a direct laringoskopiya (see). The blade of the laryngoscope is entered into an oral cavity as for an intubation of a trachea, and any tool (e.g., a Kocher's forceps) take And. t., then continue necessary resuscitation actions. If it does not work well, it is necessary to make urgently operation — a konikotomiya (see the Laryngotomy).
V. N. Semenov.
FOREIGN BODYS OF BODIES OF THE CHEST CAVITY AND DIAPHRAGM
Foreign bodys of lungs. In lungs And. t. most often get as a result of gunshot wounds. Cases of transdermal introduction to a lung of a sewing needle by hysterical persons meet. In pulmonary fabric can appear also aspirirovanny And. t., caused decubitus of a bronchial tube. More often it is observed at children.
At the time of penetration And. t. in a lung cough with allocation of a bloody foamy phlegm is usually observed. It is long being in pulmonary fabric I. t. often lead to development of inflammatory process, up to formation of abscess (fig. 22), and sometimes and gangrenes of a lung. If around And. t., being in a lung, suppurative process does not develop, it can not cause (years) any subjective and objective frustration for a long time, but as a result of action of the factors leading to decrease in protective forces of an organism (cold, infectious diseases, etc.) development of inflammatory process in lungs even after long asymptomatic stay in them is possible And. t.
Foreign bodys of a pleural cavity are observed seldom. Most often it is the tampons, pieces of drainage tubes breaking at extraction of the drainage established at this or that intrathoracic operation. In this regard for drainage of a pleural cavity it is impossible to use the rubber tubes which were repeatedly exposed to sterilization and lost durability at all. Sometimes And. t. can get to a pleural cavity at break of abscess of the lung formed around And. t.
In a pleural cavity there can be also needles entered chreskozhno. At the same time the end of a needle at the respiratory movements will wound a lung, a cut is fallen down because of the developing pheumothorax, and the needle in gravity falls in the formed free cavity. Pheumothorax in the subsequent resolves, and the needle at the same time appears in a pleural cavity, sometimes at considerable distance from the place in Coca.
Foreign bodys of a mediastinum and diaphragm — usually result of gunshot wounds. If at wound of area of a mediastinum there was no injury of vitals, then sometimes And. t. long time can not cause any frustration, however at development of inflammatory process joins it mediastinitis (see).
Foreign bodys of a pericardium and heart meet seldom and are observed usually at adults. Are slightly more often observed And. t. muscles of heart and it is extremely rare — And. t. his cavities and pericardium. In wartime prevail And. t. a fire origin, during the peace period it is needles (fig. 23) which are entered into projections of heart for the purpose of suicide by people with hysterical reactions and mental diseases. Sometimes there is accidental implementation of the needle thrust in a dress. In the form of the most rare casuistry observations of hit of needles in a muscle of heart through a wall of a gullet are described.
Cases of a drift of a needle in the right heart on veins from the remote body parts are known. In cavities of the right heart there can be also scraps of venous and cordial catheters, branches of the dilators which broke at operation. And. t. cardial cavities can migrate, leading to a vascular embolism of a big and small circle of blood circulation. However long needles, being fixed by one end, can it is long to be in a cardial cavity. Peculiar And. t. hearts are the artificial valves of heart, teflon patches, electrodes sewed by surgeons at heart operations.
Specific wedge, pictures I. t. hearts do not cause. In the acute period patients can complain of heartaches. Further long asymptomatic stay can be observed And. t. both in a muscle, and in a cardial cavity.
Radiodiagnosis of foreign bodys of bodies of a chest cavity
By means of rentgenol, researches first of all should be established where it is And. t.: in a pleural cavity, easy, in a diaphragm, heart or soft tissues of a chest wall. If at turns of the patient behind the screen a shadow And. t. it is possible to remove out of limits of outside contours of edges or to displace it at palpation, it means is located in soft tissues of a chest wall. Certain diagnostic difficulties arise at an arrangement And. t. in mezhreberye, juxtaspinal areas and in the field of tops of lungs. In these cases it is recommended to investigate the victim during inclinations forward or back. So, at localization And. t. in muscles of a back its shadow during an inclination of the patient is displaced up forward, i.e. aside, opposite to the direction of shift of the tail of an adjacent edge. At an inclination of the patient back a shadow And. t. it is displaced from top to bottom while the back department of an edge rises up. If. t. it is located intratorakalno, at an inclination it is displaced up, moving is opposite to the movement of the back ends of edges. To specify situation I. t. at similar localization pictures with the shift of a X-ray tube help and stereox-ray analysis (see). And. t., located in a lung, at multiaxial raying it is not removed for internal contours of a skeleton of a thorax, and at sharp deep breath or cough it moves in one direction with a diaphragm. At the same time it is important to establish localization And. t. in a certain share or a segment of a lung.
Rentgenol, a research allows to find changes in lungs and a pleura as close And. t., and on the course of the wound channel (infiltration, hemorrhages in tissue of a lung, development of abscess, fibrous changes in lungs, pleurisy, an atelectasis etc.). And. t., projected at an inner edge of edges, can be located in a pleura, a parakostalny hematoma, without getting into tissue of a lung. In these cases to differentiate intrapleural and intra pulmonary localization And. t. overseeing by the movements I help. t. during a breath and an exhalation, the pictures of a thorax made on a breath and an exhalation, and if necessary diagnostic pheumothorax (see. Pheumothorax artificial ). In the presence of air in a pleural cavity a reliable sign of intrapleural localization And. t. its movement at change of position of the body investigated is. If. t. it is localized in surface layers of a lung, during the imposing of artificial pheumothorax it is displaced together with a lung towards a root. At deeper arrangement And. t. in a lung it is important to establish a ratio it with elements of a root of a lung, bronchial tubes and large vessels. It is promoted by pictures of a thorax in direct (fig. 24) and side projections, a tomography, and sometimes and angiopulmonografiya (see).
And. t. mediastinums at roentgenoscopy and on direct roentgenograms of a thorax are projected on a breast or a backbone and because of imposing of their shadows, and also shadows of heart and large vessels are sometimes difficult distinguishable. At a research in a side projection And. t. a front mediastinum are located directly behind a breast in retrosternal space and quite often border on a shadow of heart or trachea. At breath And. t., located in an upper part of a front mediastinum, are practically not displaced. And. t., located in cellulose of a lower part of a front mediastinum, as a rule, at a deep breath are displaced up (along with edges), and during the pressing on a xiphoidal shoot — kzad. At localization And. t. in upper parts of a postmediastinum, near a gullet, sometimes it is possible to observe shift And. t. during deglutitory movements. The contrast research of a gullet, and also a tomography specify the topical diagnosis.
Radiodiagnosis And. t. diaphragms, especially located in a projection of a shadow of a liver or near a backbone, demands use of more hard rays. For specification of relationship And. t. and diaphragms apply side and tangential pictures, and also a tomography. And. t., located in a diaphragm, make at breath of the movement, identical in the direction and amplitude with the movements of the respective sites of a diaphragm. Shift And. t. diaphragms at breath can be determined by the picture made on one film with double exposure (on a breath and an exhalation). Rentgenokimografiya (see) and X-ray cinematography (see) allow to establish as the direction of the movements I. t. and diaphragms, and their amplitude that is especially important at a research of the diaphragm fixed by commissures and those its sites where shifts normal are expressed poorly (e.g., in the tendinous center, a front slope, etc.) - At an arrangement And. t. teeth in a kimogramma reflect the unidirectional and synchronous movements of a diaphragm in a diaphragm and And. t. In certain cases for definition of a ratio And. t. and diaphragms resort to imposing of artificial pheumothorax or pneumoperitoneum (see). Pheumothorax is effective in case of epiphrenic localization And. t., the pneumoperitoneum allows not only to define subphrenic localization And. t., but also to establish possible wound of a diaphragm.
Metal And. t. in heart or a pericardium define by a polyposition research. At endocardiac localization a shadow And. t. it is not possible to remove for contours of a cordial shadow. It is sometimes difficult to define whether is And. t. in a pericardium or in periblasts of a myocardium. In this case the rentgenokimografiya helps. At an arrangement And. t. in a cavity of a pericardium and availability in it of air or liquid it is possible to observe shift it at a postural change of the patient. And. t., located in a myocardium, it is displaced synchronously with a heartbeat. And. t., being in cardial cavities, makes the chaotic whirls caused by shift its blood flow. Knowing a X-ray anatomic projection of cardial cavities, it is possible to define localization And. t. To specification of localization And. t., located in interventricular or interatrial partitions, and also in valves or papillary muscles of heart, can promote angiocardiography (see). Movement And. t. from one cardial cavity in another and from cardial cavities in large vessels it is observed extremely seldom and it can be established only at a dynamic rentgenol, a research.
Signs of okolososudisty or intravascular situation I. t. its pulsatorny shifts, synchronous with a pulsation of vessels, and also possible movement are And. t. with a blood flow in case of its arrangement in a gleam of a vessel. At establishment of an intravascular arrangement of PI. t. it is necessary to make an angiography for specification of nature of damage of a vessel.
Removal of foreign bodys of bodies of a chest cavity
As soon as possible after wound all are subject to operational removal large And. t. lungs. In early terms operation is technically easier feasible and, as a rule, consists at a distance only And. t. In the remote terms, certainly, extraction is shown And. t., which stay in lungs is followed by development of complications (abscesses, repeated pneumonia, etc.). At absolutely asymptomatic long stay And. t. in lungs of indications to their removal is not present if at an angiography changes in vessels in the field of their arrangement do not come to light.
At operation in late terms after wound, in the presence of inflammatory process around And. t. it is necessary to resort to a segmented pneumonectomy (see. Segmentectomy of a lung ), and sometimes and to a lobectomy (see. Lobectomy, lung ).
The indication to removal And. t. to a pleural cavity serves danger of development of suppuration or the available suppuration supported And. t. The drainage tube usually manages to be taken from very small section, having precisely projected it previously on a chest wall by means of a multiaxial rentgenol, a research.
Indications and contraindications to removal And. t. hearts are considered in each case individually. Even at long asymptomatic stay in a muscle of heart ferriferous And. t. there is a corrosion of metal and treatment of surrounding fabrics iron oxides. It causes dystrophy of a myocardium and can lead to development of suppuration. Finding of a part or all needle in a cardial cavity causes danger of injury of papillary muscles, valves of heart and the carrying-out system. Finding of a part of a needle in pericardiac fabrics because of cordial reductions can cause extensive destruction of a myocardium with bleeding in a cavity of a pericardium and cardiac tamponade (see).
Operation should be made under control of X-ray television (see. Television in medicine ). The needle from a cavity or a wall of heart sometimes manages to be removed without section of its wall with method of a vykalyvaniye (as from hypodermic cellulose).
FOREIGN BODYS of DIGESTIVE TRACT AND ABDOMINAL CAVITY
And. t. went. - kish. a path occur very often at people of different age, but especially at children. Majority And. t. freely passes on a digestive tract and it is removed in the natural way. Get stuck at this or that level of hl. obr. And. t., the having rather big sizes or keen edges and thorns. To jamming And. t. can promote patol. changes of various departments of a digestive tract (cicatricial or tumoral narrowing, segmented spasm, inflammatory infiltrate, prelum from the outside).
Most often And. t. get in went. - kish. a path with food. Intentional proglatyvaniye I.T is sometimes observed. the hysterical persons, mentally sick, and sometimes and for the purpose of mutilation. During war And. t. get into an abdominal cavity and went. - kish. a path as a result of wounds.
Often small children swallow these or those objects. Cases when in went are frequent. - kish. the path of children gets mercury from the medical thermometer. The child accidentally bites off a tip of a thermometer and swallows mercury together with small splinters of glass. These cases do not constitute danger since metal mercury in went. - kish. a path it is not soaked up and brought out of an organism together with a glass crumb.
In a stomach And. t. get, having passed on a gullet, and only occasionally through a gastrostomy (see. Gastrostomy ) or during operation (e.g., the gauze napkins forgotten in a stump of a stomach at a resection). Multiple large And. t. a stomach are characteristic of persons with mental diseases which swallow in some cases tens and even hundreds of various objects (nails, hooks from grids of hospital beds, spoons, thermometers, etc.). Rather small And. t., even the having keen edges, as a rule, freely are evacuated in intestines, but heavy metal objects (fraction) are sometimes encapsulated in a wall of a stomach. Sharp objects occasionally are implemented into a mucous membrane; at the same time there can be a through puncture of a wall of a stomach (a long needle, a pin, a wooden splinter) with development peritonitis (see). Large And. t. at long stay in a stomach can cause the decubitus of a wall leading to bleeding or a perforation. Similar changes, and also disturbance of evacuation of food from a stomach can cause bezoara.
In a duodenum because of its fixed bends needles and other long objects which can perforate an intestinal wall quite often stop.
In a small bowel stupid And. t. are late seldom, however cases of development of obturatsionny intestinal impassability owing to a resistant spasm of a gut in a zone of an arrangement large are known And. t. (large fruit stone, gallstones, ball of ascarids, etc.).
Acute And. t. can cause perforation of any department of intestines. Sometimes the needle perforating an intestinal wall is encapsulated without development of suppuration, however the puncture of an intestinal wall acute PI is more often. t. leads to peritonitis or development of a limited abscess. At a puncture acute And. t. mesenteric edge of a gut the abscessing infiltrate which at inspection and even at operation can be taken for a malignant tumor is formed.
In a large intestine moving ahead from above And. t. are late seldom, but perforation of a wall of a gut (especially blind and sigmoid) swallowed acute is sometimes observed And. t. In rare instances even large And. t., having gone at formation of decubitus of a large intestine beyond its limits, it can be encapsulated in retroperitoneal space without formation of an abscess.
In a rectum the large bones or their conglomerates which are stuck together in a uniform lump by dense fecal masses, fecal stones can be late. Besides, And. t. can get into a rectum through an anus at medical procedures (e.g., the broken-off tip of an enema), at rectal masturbation, and also as a result of criminal acts. In the last two cases sometimes enter very large objects (long wooden and metal cores, bottles, bottles, etc.) into a rectum.
And. t. bilious channels concrements usually are (see. Gallstones ), which, passing in a duodenum, move on intestines. Large concrements can sometimes cause obturatsionny impassability.
In a free abdominal cavity And. t. vaginas, a uterus, a bladder can get by perforation of digestive organs, or at wounds of a stomach, leading to development of peritonitis. At the operative measures which are carried out with use of muscle relaxants under an intubation anesthesia, leaving in an abdominal cavity of gauze napkins, balls and tools it is observed only in the form of casuistry. The sterile gauze napkins left in an abdominal cavity even often lead to development of peritonitis or limited abscess, but sometimes they are encapsulated and do not cause frustration for many years. The gauze tampons and drainage tubes intentionally left for a certain term in an abdominal cavity also are And. t., however one end of similar And. t. always remove outside that allows to remove easily according to indications it.
If at a polyposition research is possible to remove And. t. on a short distance from the surface of skin or to surface muscular layers of an abdominal wall, it testifies to an extra peritoneal arrangement And. t., especially if it is possible to take And. t. a hand in a skin fold or to displace it at a palpation. For specification of localization And. t. at its deep arrangement the functional technique offered by V. Ya. Fridkin is applied: if. t. it is localized in an abdominal cavity, at position of the patient on spin it at breath makes the movements, unidirectional with abdominal organs. And. t. located in an abdominal wall, move at breath in an opposite direction. And. t. kidneys are displaced on intraperitoneal type. And. t. retroperitoneal space at breath are not mobile.
Special difficulties arise during the definition of localization And. t., areas of a stomach, located in boundary with a diaphragm. In these cases for topical diagnosis it is necessary to use the same ways, as during the definition of localization And. t. diaphragms (tangential pictures, longitudinal and cross tomography, pneumoperitoneum).
At rentgenol. research of an abdominal cavity apropos And. t. it is necessary to remember a possibility of paradoxical shifts And. t. in case of a phrenoplegia, about shift And. t. in hematomas, and also about their movement both in a free abdominal cavity, and in a gleam went. - kish. path. The survey X-ray analysis of a stomach, a contrast and layer-by-layer research of separate bodies, a fistulografiya help to establish not only localization And. t. at wounds of a stomach but also to find out what damages put And. t. to abdominal organs, retroperitoneal space and to walls of a stomach. At multiprojective raying and a X-ray analysis of a stomach, considering anatomic reference points (a gas bubble of a stomach, a liver edge, lumbar vertebrae, ileal bones etc.), establish anatomotopografichesky situation I. t. in relation to this or that department went. - kish. path. Research of a stomach by means of water-soluble contrast medium or a pnevmogastrografiya help to establish localization And. t. in upper parts went. - kish. path. Repeated researches allow to track it advance or to timely define its delay and level of a stop, and sometimes even antiperistaltic movements.
For diagnosis And. t. a large intestine it is necessary to contrast its not barium, but air since the baric suspension blocks a shadow And. t. also complicates the subsequent observation.
Perforation And. t. walls of a stomach or a gut radiological establish on the basis of emergence of free gas in an abdominal cavity, and also arrangements And. t. out of a gleam of a stomach or a gut and a symptom of flowing of a contrast agent out of limits of a contour of a stomach or a gut.
At a long delay And. t. in a digestive tract it is effective with to lay down. the purpose giving a dense baric suspension, edge envelops it and quite often promotes advance.
Indications to removal And. t. from a stomach and intestines arise at danger of development of complications (perforation, decubitus, obturation). So, all are subject to removal large And. t., which cannot leave independently. Abdominal pains, symptoms of obturation, bleeding or the slightest signs of irritation of a peritoneum dictate need of the emergency intervention.
At a proglatyvaniye of needles, pins of the patient it is necessary to hospitalize for a wedge, observations and rentgenol, control of their passage on a digestive tract. In most cases needles after several days leave in independently natural way. From a stomach and a duodenum the needle sometimes manages to be removed gastroduodenofibroskopy, from a large intestine — kolonofibroskopy (see. Gastroscopy , Duodenoskopiya , Kolonoskopiya ). From a straight line and distal department of a sigmoid gut the needle is deleted through a tubular rektoromanoskop (see. Rektoromanoskopiya ). Large And. t. delete from a rectum through an anus by means of rectal speculums. The best conditions for removal are created by an anesthesia with muscle relaxation. Extraction large And. t. from a stomach, thin and thick guts make by means of a laparotomy with gastrotomy (see) or enterotomy (see).
FOREIGN BODYS of the BLADDER AND the URETHRA
Foreign bodys of a bladder
In a bladder And. t. can get through an urethra, through a wall of a bladder at its wound, through an epitsistostomichesky opening or on an ureter.
The most frequent is the urethral way of hit And. t. in a bladder, it is more often observed at women. Such And. t. enter into an urethra or for the purpose of masturbation (head hairpins, pencils, stearin candles and so forth which accidentally slip in a bladder), or it is wrong in attempt to make abortion — rubber catheters, etc. (fig. 25). And. t. can appear in a bladder as a result of medical endovesical manipulations (the broken-off parts of a rubber catheter or an elastic buzh, a bulb from cystoscopes and so forth).
Through a wall of a bladder in his cavity And. t. get at gunshot wounds of a vesical wall (bullets, splinters of shells or mines, fraction, splinters of haunch bones, scraps of clothes), at operations (gauze balls, tampons, drainages), and also as a result of migration And. t. from an abdominal cavity, a small pelvis in a bladder through decubitus of its wall or from the paravesical abscess opened in a gleam of a bubble.
Through an epitsistostomichesky opening And. t. (pieces of a rubber tube, a head from pezzerovsky catheters) get into a bladder more often during the change of suprapubic drainages.
On an ureter urinary stones can come to a bladder, alloyed threads, bullets, etc. are more rare.
In a bladder And. t. can freely move or are fixed to a vesical wall.
Presence And. t. in a bladder can cause traumatic in the beginning, and later and inflammatory changes in a mucous membrane which extent in many respects depends on size, a form and structure And. t.
Majority And. t. in a bladder is exposed to incrustation by salts, forming concrements (tsvetn, the tab., the Art. of Ltd company, fig. 00). Fabric, bone and wooden And. t. quickly become covered with salts, metal and glass — more slowly, at all do not become covered with salts I. t., having a wax surface.
Clinical picture I. t. a bladder it is various. Leaders are dysuric symptoms in the form of increase and morbidity of an urination which quite often are followed by terminal hamaturia (see). Small And. t. with a smooth surface can not cause symptoms whereas sharp-pointed And. t. are more often shown by sharply expressed symptoms: the bladder pains amplifying at an urination, the movement, irradiating in a balanus or a crotch and ceasing at rest, a hamaturia. The symptom of a discontinuous stream of urine is sometimes noted. Later, with accession of an infection, there is a pyuria (see. Leukocyturia ). Sharp-pointed, oblong shape And. t. at reduction of a vesical wall can perforate it with the subsequent development of uric infiltration or peritonitis, depending on the place of a perforation of a bladder. At perforation of a wall of the next hollow body (a gut, a vagina) And. t. in rare instances can come to light. Extremely seldom similar perforation can lead to education vesical and intestinal (see. Intestinal fistulas ) or vaginovesical uric fistula (see. Urinogenital fistulas ).
Diagnosis And. t. a bladder is based on data of the anamnesis, cystoscopic and rentgenol, a research. In cases when patients hide or do not know about existence at them And. t. a bladder, they are brought to the doctor by the expressed symptoms of cystitis or a stone of a bladder. Tsistoskopiya (see), made in early terms, often it is sufficient for diagnosis. Only with exceptional cases when because of inflammatory changes in a mucous membrane the capacity of a bladder is sharply reduced or And. t. it is covered with fibrinopurulent films, it is difficult to establish the diagnosis at a tsistoskopiya.
And. t., located in a bladder and contrast but to the relation to X-ray, without effort are defined in survey pictures in a direct projection. When And. t. becomes a kernel of a stone, in its picture it is well visible in the center of a stone. For identification low-contrast And. t. willows doubtful cases it is recommended to make a pnevmotsistografiya (see. Tsistografiya ). At the same time against the background of gas clearly are visible even small And. t. On tsistogramma And. t. form defects of filling.
Small And. t. a bladder can spontaneously leave at an urination. In all other cases And. t. a bladder are subject to removal in the endovesical way, to Krom if he is possible, it is necessary to give preference, or an operational way. In cases, when small And. t. became a kernel of the stone formed in a bladder, it is necessary to resort to endovesical in the beginning to lithotripsy (see), and then by means of the special cystoscope to take And. t. Women thanks to anatomic features have urethras an endovesical way of removal And. t. a bladder is more often more successful, than at men.
In all cases, when endovesical removal And. t. because of its sizes and a form it is fraught with danger of injury of an urethra or in general it is impossible, it is necessary to make a suprapubic cystotomy (see. Vesicotomy ). If at operation obviously expressed inflammatory changes in a bladder are noted, then it is better to leave in it a suprapubic drainage on 2 — 3 weeks. In other cases a wall of a bladder after removal And. t. it is necessary to sew up tightly with leaving of a constant catheter for 5 — 7 days.
Foreign bodys of an urethra
In an urethra And. t. can be entered for the purpose of mischief or masturbation (hairpins, feathers, straws, peas and so forth) or owing to medical manipulations (wadded tamponchik, pieces of catheters, etc.). Extremely seldom And. t. get into an urethra by perforation of its wall. The most frequent symptom And. t. an urethra the pain amplifying or developing at an urination or an erection is. Pain can be absent if. t. has the small sizes and a smooth surface. Difficulty of an urination at a discontinuous stream of urine is at first noted only if And. t. considerably reduces a gleam of an urethra. More often this symptom appears in several days in connection with edematization of a mucous membrane of an urethra. The urethremorrhagia is more often insignificant. Later in connection with development of the accompanying inflammatory process of an urethra purulent discharges appear. As a result of distribution of inflammatory process paraurethral abscess from the outcome in uric fistula can be formed.
Recognition And. t. an urethra shall be based on the anamnesis, a palpatorny research, uretrografiya (see) and uretroskopiya (see). And. t. an urethra can be revealed in survey pictures (fig. 26) and at an uretrografiya. At full obstruction of an urethra a contrast agent reaches only the place of obstruction. At partial obstruction considerable narrowing of a gleam of an urethra in the area I is defined. t.
Small with a smooth surface And. t. urethras depart spontaneously at an urination. In the majority of cases And. t. urethras manage to be taken by means of urethral nippers, even without resorting to ureteroscopic control. Need for an outside urethrotomy for removal And. t. an urethra arises extremely seldom.
FOREIGN BODYS of the VAGINA AND UTERUS
And. t. vaginas and a uterus can be various objects: needles, a wire, spokes, fragments of tools, wooden or plastic sticks etc., the gauze or cotton plugs, rubber rings, metal caps entered with to lay down. or contraceptive purpose.
Foreign bodys of a vagina meet quite seldom — at an injury of external genitals, masturbation, a psychopathy, criminal abortion. Violent introduction And. t. in a vagina represents a casuistic rarity.
Occasionally And. t. (coins, fragments of toys, nipples) find in a vagina of girls of preschool age.
Long stay And. t. brings into a vagina to to a vulvovaginitis (see), to decubituses with possible formation of pryamokishechnovlagalishchny fistulas. Large objects, squeezing an urethra, can cause an ischuria, acute — damage walls of a vagina, the arches. Perhaps getting wound of walls of a vagina with damage of bodies of a small pelvis, abdominal cavity, bladder or rectum with corresponding a wedge, manifestations.
The injury of walls of a vagina, as a rule, is followed by considerable bleeding and demands the acute surgical management. Diagnosis And. t. vaginas is established usually without effort at survey, kolposkopiya (see).
Treatment — extraction And. t. with after-treatment of a vagina. Before removal And. t. it is recommended to enter liquid or vegetable oil into a vagina that facilitates extraction and reduces a possibility of an injury. At suspicion of the getting wound or a considerable injury of a vagina And. t. it is necessary to take in the conditions of the operating room. The volume of surgical intervention is solved on the operating table. At girls at the persistent, not giving in to conservative treatment vulvovaginitis it is necessary to exclude existence And. t. vaginas.
Foreign bodys of a uterus. Introduction And. t. in a cavity of the uterus it is most often caused by the contraceptive purpose. At the beginning of the 60th 20 century introduction of intrauterine contraceptive means was widely adopted. Apply X-ray contrast polyethylene or nylon spirals, loops, umbrellas, metal rings and their modifications. Introduction to their healthy women in a wedge, conditions, as a rule, does not cause complications. More rare various And. t. enter into a cavity of the uterus for abortion. Entered in unsterile conditions, they can cause heavy septic complications or lead to perforation of a uterus, damage of vessels or the next bodies — a bladder, an epiploon, loops of intestines or rectum.
In the absence of an infection And. t. the small sizes, burgeoning elements of connecting fabric, it can be encapsulated and inlaid with salts, remaining in a cavity of the uterus long time without wedge, manifestations or being followed by long and plentiful periods. Infection And. t. leads to inflammatory process of a mucous membrane and a muscular layer of a uterus that is followed by fervescence, pains in the bottom of a stomach, sometimes skhvatkoobrazny character, intermenstrual bloody or putreform allocations. At disturbance of pregnancy of early terms with incomplete rejection of fetal egg or at abortion of later terms the remains of fetal egg or elements of a bone skeleton of a fruit can be organized, burgeoning connecting fabric with the subsequent adjournment of salts. The organized placental polyp or the rest of a bone skeleton can be in a cavity of the uterus a long time, being, on - to a being, And. t. with the same a wedge, manifestations.
For diagnosis And. t. a uterus the metrografiya is recommended (see. Metrosalpingografiya ).
Treatment depends on the general condition of the patient, prescription of process and character of complications.
And. t. it has to be taken in the conditions of the operating room. In the absence of perforation of a uterus and a wedge, manifestations of septic process it is recommended to remove And. t. or the remains of fetal egg for what broaden the cervical channel, delete with a fenestrated forceps And. t., and then the curette make audit of a cavity of the uterus. In the subsequent carry out antiinflammatory therapy.
The established perforation of a uterus And. t., peritonitis, a septicaemia or a septicopyemia are the indication for urgent surgical intervention — a chrevosecheniye, full removal of a uterus with audit of abdominal organs.
Pathological anatomy I.T. — Voropayev M. M. and d river. Fragmental and bullet raneshsh easy for long-term prescription, M., 1974, bibliogr.; D and - in y d about in with to and y I. V. General pathology of the person, M., 1969; Lebedev L. V., P l about t to and L. L. N and With m and r N about in A. D. Prostheses of blood vessels, L., 1975, bibliogr.; M and z chenkon. S. O to tactics at sharp-pointed foreign bodys of digestive tract, Vestn, hir., t. 118, No. 3, page 55, 1977; The Multivolume guide to pathological anatomy, under the editorship of A. I. Strukov, t. 1, page 585, M., 1963, t. 3, page 474, M., I960, t. 7, page 288, 563, M., 1964; Residents of Perm N. K. and Davydovskaya N. I. Problems of resuscitation pathology, Arkh. patol., t. 36, No. 11, page 3, 1974, bibliogr.
Radiodiagnosis And. t. — Abramov Highway. I. Radiodiagnosis of fire damages, L., 1959, bibliogr.; Baklanova V. F. and Lords and on M, And. The guide to radiodiagnosis of diseases of a respiratory organs at children, page 177, L., 1978; Zed-genidze G. A. and Lindenbraten L. D. Urgent radiodiagnosis, L., 1957, bibliogr.; Kevesh E. L. X-ray inspection at nonperforating gunshot wounds of a thorax, M., 1948, bibliogr.; Kishkovsky A. N., Tyutin L. A. and With and in e of l of l about V. E. Use of an electrox-ray analysis for diagnosis of foreign bodys, Voyen. - medical zhurn., No. 6, page 27, 1975; Radiodiagnosis of diseases of bodies of a chest cavity, under the editorship of S. A. Pokrovsky, etc., page 5, Kiev, 1968; O. L Cymbals. X-ray inspection of newborns, L., 1968; I am the X N and the p I. M. Radiological diagnosis of foreign bodys, M., 1963, bibliogr.
And. t. head and spinal cord — Irger I. M. Neyrokhirurgiya, M., 1971; Lebedev V. V., etc. Bullet wounds of the head of peace time, Voyen. - medical zhurn., No. 1, page 24, 1971; Lebedev V. V., etc. Radiodiagnosis of traumatic injuries of a skull and brain, M., 1973, bibliogr.; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 4 — 5, M., 1949, 1953; Surgery of the central nervous system, under the editorship of V. M. Ugryu-mov, p.1, page 674, L., 1969.
And. t. eyes — Weinstein E.G. Bases of radiodiagnosis in ophthalmology, M., 1967, bibliogr.; In about lx about in V. V., about r and N A. I. and D is scarlet and and sh in and l and O. A. Clinical trial of an eye by means of devices, L., 1971; Gundorova R. A. and Peter and Paul G. A. The getting wounds and contusions of an eye, M., 1975, bibliogr.; Dambite G. R. Metalloz of an eye and its treatment, M., 1971, bibliogr.; D and l and and sh in and l and O. A. and H at shopping mall about M. B. Acute ophthalmologic management, L., 1973, bibliogr.; L eb e X about in P. I. Perforated wounds of eyes, JI., 1974, bibliogr.; Levkoyeva E. F. A wound process in an eye, M., 1951, bibliogr.; The multivolume guide to eye diseases, under the editorship of V. N. Arkhangelsky, t. 3, book 2, M., 1962; Pole B. L. Povrezhdeniya of an organ of sight, L., 1972, bibliogr.; The guide to eye surgery, under the editorship of M. L. Krasnov, M., 1976; With about m b e of g W. Ein neues Verfahren zur Rontgenlokalisation mit Augap-fel, v. Graefes Arch. Ophthal., Bd 118, S. 175, 1927; System of ophthalmology, ed. by S. Duke-Elder, at. 14, pt 1—2, L., 1972.
And. t. fish soup, nasal cavity, throat, throat, trachea and bronchial tubes — Questions of otorhinolaryngology of children's age, under the editorship of I. I. Shcherbatov, century 3, page 43, etc., M., 1965; To about z and c to and I am K. N. Foreign bodys of respiratory tracts, Kiev, 1969, bibliogr.; Lepnev of II. G. Klinika of foreign bodys of a throat, trachea and bronchial tubes, L., 1956, bibliogr.; L at to about m with to and y G. I. and Berezov Yu. E. Endoskopicheskaya of the technician in surgery, M., 1967; Bridge S. I., Makukh A. L. and L at c of e of the Tax Code about V. A. Metod of removal of the opened pins and to them similar foreign bodys from a trachea, bronchial tubes and a gullet, Zhurn, ushn., Nov. and throats, Bol., No. 1, page 119, 1970; Rada of and K. B. N, Nevsky B.N.i Shapiro L. M. Foreign bodys of a laryngopharynx and gullet, M., 1973, bibliogr.; Smirnov G. A. and Romm of Page 8. Acute management at diseases and injuries of an ear, throat and nose, L., 1974, bibliogr.; T r at t of N of e in V. K. Trakheobronkhoskopiya, M., 1952, bibliogr.; it, Tracheotomy, M., 1954, bibliogr.; At V.F's ndritsa. Acute stenoses of a throat, M., 1950, bibliogr.; F l and and N with to and x N. A., etc. Foreign bodys of respiratory tracts at children, Zhurn, ushn., Nov. and throats, Bol., No. 6, page 71, 1976; Surgical diseases of a throat. throats, tracheas, bronchial tubes and a gullet, under the editorship of V. G. Yermolaev, M., 1954; Shcherbatov I. I. and Chistyakova V. R. Foreign bodys of respiratory tracts at children's age, M., 1970, bibliogr.; And 1-N a m a n J. D., And 1-A n i M. S. and. And 1-A n i H. R. Non-vegetable foreign bodies in the bronchopulmonary tract in children J. Laryng., v. 89, p. 289, 1975; D i m i t-r i u A. V., FiricaD. GiobanuM. Gorpii strani traheobron^iu (consideratu in legatura cu 1030 de cazuri), Rozhl. Chir., v. 53, p. 239, 1974; Moussavi H. Abbas s-Z a d e h S. Removal of bronchial foreign body, J. Laryng., v. 88, p. 95, 1974; Operative surgery, ed. by J. Ballantyne, v. 1—2, L., 1976; R e h life k L. Unusual complications caused by a foreign body in the tracheobronchial tree, Laryngoscope (St Louis), v. 85, p. 1767 1975, bibliogr.; Zavala D. C. a. R h o-d e s M. L. Foreign body removal, new role for the fiberoptic bronchoscope, Ann. Otol. (St Louis), v. 84, p. 650, 1975.
And. t. hearts, lungs and pleural cavity — Vinogradova O. I. and F and the Dr. at with E. I. Acute foreign bodys of heart and pericardium, Surgery, No. 10, page 74, 1964, bibliogr.; Voropayev M. M., etc. Remote effects of slight nonperforating gunshot injuries, M., 1965, bibliogr.; In about r about x about about in L. A. and the Oryol S., the Item. Operational treatment at foreign bodys of lungs at children, Surgery, No. 7, page 57, 1965, bibliogr.; Zemskov H. H., G e of N of the p e of N to about I. P. and Chichetk A. A. Foreign bodys of bronchial tubes and pulmonary parenchyma, Grudn. hir., No. 6, page 102, 1973; Ivanitskaya M. A., Petrosyan Yu. S. and the X ohm at t about in and M. G. Rentgenokinematografiya in diagnosis of heart diseases, M., 1971, bibliogr.; P and to and N And. X. and And to-perbekov A. A. Radiodiagnosis of diseases and damages of a diaphragm, M., 1973, bibliogr.; Helmer F. u. Uye with s e i Y. Jatrogener Fremdkorper im rechten Herzen infolge Spiralenabrisses beirn Anlegen eines oberen Hohlvenenka-theters im Rahmen der Intensivpflege, Z. prakt. Anasth. Wiederbeleb., Bd 8, S. 173, 1973.
And. t. digestive tract — Begak E. D. Foreign bodys in a gullet at children, Works Leningr, pediat, medical in-that, t. 63, page 18, 1974, bibliogr.; At l about r d and in and Ul. And. and To about f to and N of A.C. Foreign bodys of digestive tract, Tallinn, 1969, bibliogr.; To a fini and N. N. N. The abacus at M. M. m and P au times of A. N. The emergency ezofagoskopiya at foreign bodys and injuries of a gullet, Surgery, No. 11, page 132, 1976, bibliogr.; To at r and l and I. A N. Foreign bodys of a gullet, Kiev, 1977; M z-x about in with to and y V. 3. isemenenyep. B. Indications to operational removal of foreign bodys Yelu D ochn about - ki sh with chn about about a path, Surgery, No. 6, page 78, 1975, bibliogr.; P and Russia to P. V. and d river. To diagnosis of bezoar of a stomach, Vestn, hir., t. 116, No. 6, page of ill, 1976; P e r m I to about in V. N. and Lehman V. P. About extraction of foreign bodys from a stomach by means of the gastro-fiberscope, Klin, hir., No. 5, page 71, 1976; B. S rose trees. Foreign bodys and injuries of a gullet and related complications, M., 1961, bibliogr.; T a shouting about p about in Yu. D. Neprokhodimost of intestines, caused by the foreign bodys left in an abdominal cavity, Klin, hir., No. 9, page 53, 1974, bibliogr.; F e of l dm and A. I N. Diseases of a gullet, M., 1949, bibliogr.; X and with and l of e in and A. F., r and - in and c to and y V. S. and With m about l sh and N and O. V. Issledovaniye of patients with metal foreign bodys gastrointestinal traktd, Surgery. No. 10» page.40, 1972; 4cf) 'an of N yu to G. M. Foreign body of an awn, belly on JI, in the same place, No. 9, page 117, 1972‘; Sh e x t of m and B.'s N of III. Conservative treatment of patients with foreign bodys of digestive tract, in the same place, No. 6, page 74, 1975, bibliogr.; S a b e t i H. a. H and with h e m i a n D. 'J. Pronostic 'actuel des corps etrangers des voies a6riennes et digestives? Ann. Otolaryng. (Paris), t. 92, p. 315, 1975.
And. t. bladder and urethra — Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 13, page 59 and other. M, 1955; The Guide to clinical urology, under the editorship of A. Ya. Pytel, page 85, 597, M., 1970, bibliogr.; Frumkin A. P. Cystoscopic atlas, M., 1954.
And. t. vlagaliishch and uterus — Petrov-Maslakov M. A. and d river. Modern contraceptives, L., 1973; With e of l of e I am N of e in and N. D. Acute management in gynecology, page 79, 95, etc., M., 1976; A p e 1 about R., Ramos R. and. Thomas M. The LEM device in an immediate postpartum contraception program, Fertil. and Steril., v. 27, p. 517, 1976; Ludwig Hv Das Intrauterininpessar zur Kontrazeption, Geburtsh. u. Frauen-heilk., Bd 36, S. 97, 1976, Bibliogr.; Mead P. B., Beech am J. B. a. Maeck J. V. Incidence of infections associated with the intrauterine contraceptive device in on isolated community, Amer. J. Obstet. Gynec., v. 125, p. 79, 1976; R o the K. Methoden der Empfangnis-verhiitung, Jena, 1973.
H. H. Kanshin, B. D. Komarov; E. S. Weinstein, R. A. Gundorova (oft), Yu. S. Ioffe (neyrokhir.), N. A. Klitskaya (gin.), I. L. Kruchshshna (ENT specialist.), V. P. Nemsadze (it is put. hir.), Ca reap M. A. it is new (a stalemate. An.), E. M. Ustimenko (Ur), L. M. Freydin, M. K. Shcherbatenko (rents.).