PLEURISY (pleuritis; grech, pleura an edge, a side + - itis) — an inflammation of a pleura. In most cases P. is not an independent disease and represents patol, the process complicating the course of these or those diseases of lungs and, much more rare, a chest wall, a mediastinum, a diaphragm or bodies under phrenic spaces. Despite the secondary nature of almost all inflammatory and reactive processes in a pleura, in some cases they define features of a current, and sometimes make heavier a current of a basic disease and quite often demand acceptance of special medical measures.
On P.'s etiology it is possible to divide into infectious and noninfectious (aseptic). Infectious P. is subdivided depending on character of the infectious activator which caused it (staphylococcal, pneumococcal, putrefactive, anaerobic, tubercular, koktsidioidozny, echinococcal etc.), and noninfectious — depending on character of a basic disease, manifestation or a complication of which it is (rheumatic, carcinomatous, traumatic, etc.). Depending on the nature of fabric changes distinguish dry (fibrinous) P. and vypotny (exudative) to mark out P. Sleduyet that similar division not absolutely precisely as inflammatory exudation is characteristic of any P., including fibrinous. By Vypotna P. depending on character of an exudate it is subdivided on serous, serofibrinous, purulent, putrefactive, hemorrhagic and chyle. If to a purulent exudate gas (more often air is added at break in a pleural cavity of abscess, a cavity, an emphysematous bubble), there is pheumothorax.
On a wedge, to P.'s current happens acute, subacute, chronic.
Depending on existence or lack of an otgranicheniye of an exudate from not struck pleural cavity distinguish the diffusion (total) and delimited (sacculated) P., and according to localization sacculated an exudate subdivide the last into apical (apical), pristenochny (parakostalny), kostodiafragmalny, phrenic (basal), paramediastinal, interlobar (interlobarny) — fig. 1.
Data on a possibility of accumulation of an exudate in a pleural cavity were available already in the ancient time. So, in Hippocrates's works (5 — 4 centuries BC) and K. Galen (2 century AD) it is mentioned evacuation of pus from a pleural cavity by means of a section (puncture) of a chest wall. In 18 century G. Van-Sviten, etc. began to allocate P. as an independent patol, process. At the beginning of 19 century in R. Laennek (1819 — 1821) works the bases of fmzikalny diagnosis of P. which expanded opportunities its wedge, recognitions were developed. P.'s diagnosis gained further high-quality development at a boundary of 19 and 20 centuries as a result of opening and introduction to practice rentgenol, methods of a research of bodies of a chest cavity.
During the first and second world wars purulent P. (an empyema of a pleura) were the most frequent and heavy complication of the getting gunshot wounds of a breast. During this period methods of treatment of this type of pathology of a pleura began to be developed in details. This problem gained further development as a result of bystry development of pulmonary surgery in post-war years.
is not present the Reliable statistical data concerning the general incidence of P. and mortality from it neither in domestic, nor in foreign literature. It is connected first of all with the fact that in most cases P. is registered under headings of diseases which complication it is. Besides P. often proceeds without expressed a wedge, symptoms, masks manifestations of the basic patol, process and is not distinguished in general. About P.'s frequency it is possible to judge indirectly by the frequency of the unions which are found during autopsy in a pleural cavity as they are a consequence of the postponed inflammation of a pleura. According to Itida (Ichida, 1936), unions between a visceral and parietal pleura during openings were found in 48% of the persons who died from accidents and at 80,5% of the dead of these or those diseases.
For the last decades the relative frequency and value P. of various origin significantly changed. According to V. A. Ravich-Shcherbo and V. M. Goldfeld (1933) and G. R. Rubenstein (1949), to the middle of 20 century tuberculosis was the most frequent cause of exudative P. Further as a result of progress in prevention and treatment of tuberculosis situation significantly changed. So, according to Mettsel (Metzel, 1978), in 40,8% of cases malignant new growths (a carcinomatosis, mesothelioma of a pleura) whereas the tubercular etiology of P. was established only in 20,6% of cases were the reason of a pleural exudate.
As the vast majority of P. is a complication or manifestation various, preferential pulmonary, diseases, P.'s etiology conditionally consider a cause of illness, a cut led to emergence of the Item.
From the point of view of an etiology all P. can be divided on infectious, (including infectious and allergic), that is the pleurae tied with an invasion contagiums or allergic reaction of a pleura to the sub-plevralno localized infection, and noninfectious, or aseptic at which inflammatory process in a pleura arises without direct participation of pathogenic microorganisms.
Infectious P. most often cause those types of pathogenic microorganisms, to-rye inflammations of respiratory departments of lungs are the reason acute or hron. So, croupous, or share, the pneumonia caused preferential by a pneumococcus or its associations at a typical current, as a rule, is complicated by P. that gave the grounds to call it a pleuropneumonia. The acute focal pneumonias which also have in most cases the coccal nature quite often are complicated by the Item. The frequent reason it is long the current serous and serofibrinous P. tuberculosis is. Tubercular P. meets as independent a wedge, a form of tuberculosis, and also at the focal, disseminated, infiltrative pulmonary tuberculosis, tuberculosis intrathoracic limf, nodes and other displays of a tuberculosis infection. Tubercular P. often develops at primary pulmonary tuberculosis (see. Tuberculosis of a respiratory organs ) as one of its manifestations. More frequent emergence of tubercular P. at persons of young age and teenagers is explained by it. Rather seldom tubercular P. represents one of manifestations of systemic tubercular lesion of serous covers (polyserositis). Purulent P. (an empyema of a pleura) can have extremely various etiology, and pyogenic cocci act as activators on the first place. According to M. I. Kuzina (1976), most often the activator of an empyema of a pleura is staphylococcus (37%), is slightly more rare — a streptococcus (27,2%) and gram-negative sticks (pyocyanic sticks, proteas etc. — 23,9%), is even more rare — diplococcuses (6,5%). Especially heavy empyemas complicating gangrene of a lung can be caused by anaerobic and putrefactive microflora (anaerobic and putrefactive P.).
P. of the fungal nature are known: at a coccidioidomycosis, a zymonematosis and other fungal infections, and also the parasitic P. resulting from break in a pleural cavity of an echinococcal cyst and an invasion of a pleura other parasites, napr, trematodes (Parago-nimus westermani).
Noninfectious (aseptic) P. can develop as a result of hemorrhage in a pleural cavity (so-called traumatic P.). Very often P. connected with a carcinomatosis of a pleura as a result of dissimination on the surface of a pleura of bronchogenic cancer or cancer tumors of other localization, and also primary tumors of a pleura (mesotheliomas) meet. Exudation in a pleural cavity can accompany also general diseases of connecting fabric: rheumatism, a system lupus erythematosus, a scleroderma, a dermatomyositis, a nodular periarteritis (see. Collagenic diseases ). Often pleural exudate appears at an acute heart attack lung (see) as a result of a thromboembolism of branches of a pulmonary artery.
the Pathogeny of pleurisy is in the closest dependence on the reasons causing it. At the vast majority of patients with vypotny P. the crucial role in development and the course of a disease is played by the changed reactivity - it is P. of the so-called infectious and allergic nature. In a chain of pathogenetic links at P. of infectious and allergic genesis it is possible to allocate conditionally the stage of a sensitization of a pleura proceeding subclinically during which repeated receipt from the center of an infection in a subpleural zone of a lung and a pleura of antigens — microbes, products of their life activity (toxins), and also proteinaceous and high-polymeric proteinaceous polisakharidnykh the complexes which are formed as a result of the damaging action of microbes on fabric and the changed fabric exchange is observed. To to antigens (see) corresponding are developed and collect antibodies (see). As a result of a meeting in a vascular bed and a connective tissue basis of a pleura of antigens and antibodies a large amount of biologically active agents is formed: histamine (see), serotonin (see), etc. Together with products of the changed exchange they cause local disturbances of blood circulation, damage of an endothelium of vessels that leads to increase in permeability of a vascular wall (see. Permeability ), to formation of an exudate and damage of the bedded avascular structures of a pleura playing a role of a fabric barrier. Thus, damage of vessels and a connective tissue basis of a visceral pleura leads to development of exudative pleurisy. Along with exudation loss of fibrin in thickness and on the surface of a pleura is observed.
In other cases, for example at purulent P., immediate effect of the microbes planting a pleura obviously prevails.
Ways of penetration of contagiums to a pleural cavity at P. of infectious genesis are various. Direct infection of a pleura comes from subpleural patol, the centers. According to S. I. Spasokukotsky (1938), infection of a pleural cavity with pyogenic microorganisms practically is always preceded by break in a pleural cavity of a subpleural suppurative focus. Transition of inflammatory process from pulmonary fabric to a pleura can happen limfogenno (lymphogenous P.) that, according to D. A. Zhdanov (1946) and Item A. Tepper (1952), it is carried out so-called retrograde, or centrifugal, by current of an intercellular lymph which can take out activators of an infectious inflammation from depth of a lung in a pleural cavity. Distribution of contagiums from subpleural patol, the centers in the hematogenous way (hematogenous P.) is observed much less often. Direct hit of contagiums in a pleural cavity from a wound of a chest wall or from the infected pulmonary fabric and pneumatic ways which integrity can be broken takes place in surgical practice at wounds of a breast and operative measures. For tubercular P. infection of a pleura with mycobacteria from struck with tubercular process bronchopulmonary limf, nodes, the subpleural centers or as a result of break in a pleural cavity of cavities with formation is characteristic pyopneumothorax (see). At noninfectious P.
increase in fabric and vascular permeability of a subpleural zone of lungs and the pleura is also the cornerstone of pleural exudation. Traumatic P.' development is connected with inflammatory reaction of a pleura to the blood which streamed in a pleural cavity. At the low-changed pleural covers and small volume hemothorax (see) the streamed blood remains in liquid state or the clot formed in the beginning lyses. In this case in the absence of infection blood as if gets divorced a pleural exudate, erythrocytes gradually collapse, and the liquid exudate rich with hemoglobin is slowly soaked up, leaving afterwards rather small unions. The traumatic hemothorax, especially at considerable destruction of fabrics of a chest wall and a lung, followed by release of a large number of fabric factors of coagulation, usually leads to formation of the massive, not exposed to a fibrinolysis clot which at an aseptic current of P. is exposed to the slow organization with formation dense shvart, limiting function of a lung.
The pleural exudate at a carcinomatosis of a pleura arises, on the one hand, under impact on a pleura of products patol, exchange, allocated by a tumor, with another — as a result of blockade by metastasises of outflow tracts of a lymph in the field of a root of a lung and a mediastinum, and also blockade of stomas and hatches of a parietal pleura (see. Pleura ) owing to dissimination of a tumor on a pleura, and also destruction of serous covers of a pleura at development or at germination of a tumor from the subject fabrics.
Emergence in a pleural cavity of a hemorrhagic exudate at destructive pancreatitis is connected with lymphogenous penetration into a pleural cavity of the active enzymes of a pancreas, in a large number found in a pleural exudate.
In education, accumulation and the subsequent rassasyvaniye of a pleural exudate at P. of various etiology interaction of three factors matters: inflammatory exudation from a visceral pleura, pressure in the pleural cavity and ability which remained not changed departments of a parietal pleura to a resorption.
Braking of process of absorption of an exudate at the height of exudation is connected with a prelum limf, vessels of a parietal pleura and disturbance of their functions, closing of stomas and hatches between mesothelial cells the dropping-out fibrin, disturbance of the respiratory excursions of a lung playing a role of the pump, and weakening of work of the heart displaced by an exudate. Under certain conditions, for example planting of a pleura tubercular hillocks, penetration of a purulent or putrefactive infection, processes of exudation and resorption can be broken for a long time.
At involution patol, the process which caused P.'s emergence, a liquid part of an exudate rezorbirutsya gradually, fibrinous imposings are exposed to the organization by connecting fabric with education shvart and unions, partially or completely obliterating a pleural cavity. However the purulent exudate under no circumstances cannot independently rezorbirovatsya, its elimination from a pleural cavity is possible only as a result of break outside through a chest wall, in bronchial tubes or as a result of medical manipulations (evacuation by means of a puncture or drainage).
The pathological anatomy
Dry (fibrinous) P. is characterized by lack of a free liquid exudate in a pleural cavity. The surface of a pleura dim, is covered with a thin grayish film or flocculent masses fibrin (see), to-rye in the first days easily, and later when the organization begins, difficult act from its surface. To fibrin in this or that quantity are added macrophages (see), plasmocytes (see), lymphocytes (see), granulocytes. In the course of the organization fibrin resolves and replaced with connecting fabric that leads to a fibrous thickening of a pleura. Development of commissures and synechias is typical for fibrinous P.'s outcome, to-rye have tyazhe-shaped, filmy or plane character, richly in a vaskulyarizirovana, are innervated, quite often contain vessels of the closing type and the bunches of smooth muscle fibers which are not connected with vessels. Fibrous fabric in commissures alternates with layers of fatty tissue, sometimes is exposed to a hyalinosis, petrification. In rare instances after fibrinous P. in a pleural cavity there are so-called fibrinous bodies — round or oval educations from fibrin.
Serous P. meets seldom, more often it is followed by a small exudate of fibrin and has seroznofibrinozny character. Seroznofibrinozny P. is microscopically characterized by expansion circulatory and limf, vessels of a pleura, sometimes thrombosis, increase in permeability of their wall for leukocytes and macrophages, to-rye together with a liquid part of an exudate get into a pleural cavity. The mesothelium of a pleura is exfoliated, and it takes a dim form. If impurity of fibrin is big, there is a film, thicker in basal departments where sometimes on it fibers owing to adhesion of a parietal and visceral pleura are formed during the respiratory excursions. The pleural exudate has an appearance of muddy liquid of yellow color with flakes of fibrin. Specific weight higher than 1,016; in draft lymphocytes, granulocytes, macrophages, desquamated cells of a mesothelium.
The serofibrinous P. arising at various diseases has nek-ry features in each case. Rheumatic P. in addition to a serofibrinous exudate is characterized by mucoid, fibrinoid dystrophy of collagenic fibers of a pleura. At allergic diseases find a large number of eosinophils (eosinophilic P.) in an exudate. At germination of a mediastinum a tumor at a lymphogranulomatosis in an exudate there are lipids getting into a pleural cavity through a wall limf, vessels of a pleura which passability is broken owing to blockade by their tumor or prelums increased limf. nodes. The exudate and the surface of a pleura at the same time gain opalescent character. At cancer of a lung and tumors of other localization (a breast cancer, a stomach) hemorrhagic P. of which accumulation in a pleural cavity of rather turbid bloody exudate containing a large number of erythrocytes, and also cells of a tumor is characteristic quite often develops. The sharp hyperemia of a pleura, hemorrhage on its surface is observed; besides, cancer quite often develops limfangiit. Limf, the vessels stuffed with cancer cells take a form of the whitish laces acting on the surface of a pleura (fig. 2). Sometimes the pleura is planted by small metastasises.
Vypotna P. with accumulation of a serous and serofibrinous exudate is the most frequent option tubercular P. Nablyudayetsya at formation of the multiple tubercular hillocks on a pleura sometimes merging among themselves in larger centers and also at a caseous necrosis of the separate large centers. However in this case in cellular structure of an exudate neutrophils prevail. At more widespread caseous necrosis of a pleura the exudate becomes serous and purulent, and at extensive defeats — purulent. In case of break in a pleural cavity subplevralno of the located tuberculous focuses and cavities there is an extensive caseous necrosis of a pleura which is followed by also exudative inflammatory reaction of a pleura and accumulation of an exudate, quite often purulent.
At purulent P. (an empyema of a pleura) the purulent exudate accumulates preferential in lower parts of a pleural cavity. Purulent P. of the pneumococcal nature is usually combined with a fibrinous exudate and therefore it is characterized by accumulation of pus among the fibrinous «cameras» which are located in lower parts of a pleural cavity. Stafilokokki and streptococci cause purely purulent P. with accumulation of flavovirent slivloobrazny pus in the first case and liquid gray — in the second. The pleura at the same time dim, is covered with pus, sometimes a nekrotizirovana, penetrated by colonies of microbes. The mesothelium with is shelled, all layers of a pleura of an infiltrirovana by neutrocytes, macrophages, borders of layers are erased. In the presence in a pleura of thrombovasculites purulent infiltration from a visceral pleura can extend to a lung — so-called kortikoplevrit, and from parietal — on intermuscular cellulose of a chest wall.
Putrefactive P. is a consequence of penetration into a pleura of putrefactive microbes from the centers of gangrenous disintegration of the lung which complicated pneumonia, a heart attack or cancer of a lung. The exudate at the same time burovatosery with a putrefactive smell, sometimes process flows with formation of gas.
At inefficient treatment the empyema gets hron, a current: granulations cicatrize, limf, collectors of a pleura are obliterated, mesh lymphogenous develops pneumosclerosis (see). At the same time the fallen-down lung is fixed, fibrinous imposings on its surface, and also on a parietal pleura the organizations are exposed; as a result of it the rigid residual pleural cavity in which the purulent process getting hron, character remains is created, bronchopleural and plevrokozhny fistulas form. Against the background of formation of commissures, the free exudate in a pleural cavity is sacculated, condensed, sometimes turning into the kroshkovaty weight containing crystals of cholesterol (pseudochylous P.) and lime. Sometimes at extensive purulent destruction of pulmonary fabric the visceral pleura is penetrated by a set bronchial fistulas (see), so-called «trellised lung».
The functional disturbances arising at pleurisy. The pain reaction arising at dry P. as a result of friction of the parts of a visceral and parietal pleura and irritation of receptors inflamed and covered with fibrinous imposings which plentifully supplied a parietal pleura leads to restriction of depth and, respectively, increase in frequency breath (see). At accumulation of an exudate there are disturbances connected about a stake-labirovaniyem and a compression atelectasis of a lung, and also shift of a mediastinum in the healthy party. At moderate quantity of an exudate there is a restriction lung ventilation (see), and the compression collapse of a part of alveoluses can promote emergence of a moderate anoxemia due to change of a ratio between lung ventilation and a blood-groove. Shift of a mediastinum at a large number of an exudate leads to restriction of ventilation of the second lung, increase respiratory insufficiency (see) and to frustration blood circulations (see) as a result of the shift of heart, disturbance of inflow of blood to it owing to the general increase in intrathoracic pressure, an excess of venas cava that can lead to death of the patient.
At purulent P. intoxication caused by absorption by the extensive surface of a pleura of microbic toxins and decomposition products of protein (it is purulent - resorptive fever according to I. V. Davydovsky, 1954), leads to exhaustion of the patient, massive loss of protein (it is purulent - resorptive exhaustion), changes from parenchymatous bodies, first of all kidneys — toxic nephrite, an amyloidosis (see. Is purulent - resorptive fever ).
The clinical picture
the Clinical picture at P. consists of manifestations of the basic disease which was complicated by P., manifestations actually of P., and also frustration from vitals and sistekhm, allocate to P.'s clinic of various origin caused by P. V dry (fibrinous) P.'s syndrome, vypotny not purulent P.'s syndrome and purulent P.'s syndrome (an empyema of a pleura). In dynamics of a disease these syndromes can be observed separately or pass one into another.
Dry pleurisy is expression of reaction of a pleura to nonspecific inflammatory process in a pulmonary parenchyma (pneumonia, abscess of a lung), and its wedge, manifestations usually supplement symptomatology of these diseases. In other cases dry P. develops as if separately, without clear changes in a lung, napr, as a result of overcooling. In these cases reaction of a pleura, sensibilized to tubercular antigen which is emitted from the centers of an infection which are localized in bronchopulmonary limf, nodes or in pulmonary fabric and clinically not shown can be an origin of fibrinous P.
Dry P. usually proceeds sharply or subacutely. The main complaint of patients is the acute pain in the corresponding half of a thorax connected with breath. Pain is localized in a zone of emergence of fibrinous imposings and is most intensive in zadnenizhny departments of a thorax where mutual mobility of a visceral and parietal pleura is maximum. Pain amplifies at a deep breath, and also at an inclination of a trunk to the opposite side (She-pelmann's symptom). For reduction of pain patients aim to breathe superficially or accept forced situation in a bed on a sick side, immobilizing thus the struck half of a thorax. The general condition of patients usually remains satisfactory if dry P. does not accompany heavy changes in lungs. Temperature reaches subfebrile figures. The shallow breathing which is speeded up excursions of a thorax are reduced on the party of defeat. At a palpation of a chest wall on the sick party, especially at thin patients, it is possible to define the characteristic crepitation connected with breath. At apical P. moderate morbidity of trapezoid muscles (Shternberg's symptom) and muscles of a breast (Pottendzher's symptom) sometimes comes to light; there can be Horner's triad (an enophthalmos, a pseudoptosis, a miosis) owing to involvement in inflammatory and cicatricial process of branches of a cervical and sympathetic texture (see. Bernard — Horner a syndrome ); at defeat of a brachial plexus signs can appear plexitis (see). At para-mediastinal localization of P. and development of an adhesive mediastinitis <see) involvement in commissural process of branches of a vagus nerve is possible that leads to emergence of serdtsebiyeniye, sometimes to disturbance of motor and secretory function of a stomach. The main thing and in most cases the only auskultativny symptom of dry P. is the pleural rub over the field of fibrinous imposings. Sometimes the pleural rub is heard even at distance (Shchukarev's symptom). At a blood analysis acceleration ROE and a small leukocytosis can be observed.
Diagnostic difficulties can meet at phrenic dry P., to-rye quite often accompany basal pneumonia or inflammatory processes in bodies of the upper floor of an abdominal cavity (in subphrenic space). The pleural rub at the same time usually is absent, pain can irradiate on a phrenic nerve up, to the area of a neck, and on the lower mezhrebernsh to nerves to the area of a stomach, at the same time muscle tension of a stomach on the party of defeat quite often comes to light. Sometimes there is a painful hiccups, pain during the swallowing. At a palpation painful points between legs grudino - a clavicular and mastoidal muscle (a sign of Myussi), in the first intercostal spaces at a breast, in the area of an attachment of a diaphragm to edges, in the field of acanthas of upper cervical vertebrae can come to light. At auscultation in the lower shares of lungs the rattles characteristic of basal pneumonia are sometimes listened, and infiltration in basal segments of the lower share radiological is found. In some cases at phrenic P. the diagnosis of an acute disease of bodies of the upper floor of an abdominal cavity is mistakenly made and even the unreasonable laparotomy is carried out.
The current of the «isolated» dry P. is usually short. In several days of pain abate, the general state is normalized, in 2 — 3 weeks of the patient recovers. Dry P. can pass in vypotny.
Vypotna not purulent pleurisy develops sharply more often. Initial manifestations and a wedge, his picture are various. In cases when emergence of a liquid exudate was preceded by dry P., pain on the party of defeat decreases or disappears at all, being replaced by feeling of weight, overflow, an incremental asthma, progressing of weakness, fatigue. In subacute cases the specified symptoms arise gradually, imperceptibly, sometimes after the period of a febricula and small temperature increase. Dry cough of reflex character is noted. At considerable accumulation of an exudate the feeling of shortage of air at rest appears. Patients aim to accept forced situation with the raised upper part of a trunk in a bed, and lie preferential on a sick side that provides the smaller pressure of an exudate upon a mediastinum and smaller removal of the last. At survey cyanosis of integuments and visible mucous membranes, swelling of cervical veins is noted. Respiratory excursions on the party of defeat are reduced, and at thin patients with poorly developed muscles and, in particular, at children protrusion of intercostal spaces is sometimes noticeable. At considerable exudates the struck half of a thorax increases in volume. Skin in the bottom of a thorax becomes edematous, and the skin fold raised between two fingers is represented to more massive, than from the opposite side (Vintrikh's symptom). Pulse is, as a rule, speeded up. Limits of dullness of heart and a mediastinum are displaced by Perkutorno in the healthy party. On the party of defeat cordial dullness merges with the obtusion caused by a pleural exudate.
The main symptom of vypotny P. is the extensive dullness preferential in lower parts of a thorax where in the absence of unions irrespective of the place of education the exudate accumulates. The free pleural exudate is defined perkutorno if its quantity exceeds 300 — 400 ml. By data I. I. Yonkova and S. T. To-dorova (1966), at the level of obtusion on the IV edge on the sredneklyuchichny line contains in a pleural cavity of the adult patient 1 — 1,5 l of liquid, and increase in level of obtusion on one edge corresponds to increase in volume of liquid approximately on 0,5 l. The upper bound of obtusion depends on amount of liquid and has the arc-shaped form, as much as possible towering on the back axillary line (Ellis's line — Damuazo — Sokolova). However this line does not correspond as believed earlier, the upper bound of an exudate. The last, according to Davis (S. Davis, 1963), usually is horizontal. This discrepancy is explained by the fact that the upper bound of obtusion goes on level, on Krom the layer of an exudate has thickness sufficient to cause change of a percussion sound. This thickness is the greatest in posterolateral departments of a chest cavity where there is the highest point of border of obtusion. Kperedi and kzad from it a layer of an exudate becomes thinner, and percussion points in which thickness of a layer provides noticeable obtusion are located below and below.
At a big exudate on the healthy party along a backbone the dullness of triangular shape appears (Grokko's triangle — Raukhfussa). The basis of a triangle is the diaphragm, two other parties are formed by a backbone and the line which is continuation of the line of Ellis — Damuazo — Sokolova (see fig. 6 to St. Pleura ). Grokko's triangle — Raukhfussa is formed in connection with the shift of a mediastinum, and, perhaps, and overriding from the sick party on healthy parts of a pleural bag (sine) overflowed with an exudate.
At the sacculated vypotny P. borders of obtusion are located atypically and depend on the place of accumulation of liquid. At phrenic and interlobar P. obtusion can not be defined at all as the exudate does not adjoin to a chest wall.
Respiratory noise (see) over area of obtusion (in typical cases over a diaphragm where an exudate most massiven) at auscultation are usually weakened or are not listened. slightly higher — muffled bronchial breath (see), it is listened even above vesicular breath (see) with a rigid shade, and directly over the upper bound of obtusion crepitant rattles or a pleural rub are defined. Sometimes at a considerable exudate breath with a bronchial shade is listened. Voice trembling (see) in the field of accumulation of an exudate, and also bronchophony (see) are, as a rule, weakened. Sometimes at pleural exudates of average volume over the upper bound of dullness the phenomenon of a so-called egophony consisting in the nasal jingling shade of the informal conversation listened by a phonendoscope is defined.
The clinic and not purulent vypotny P.' current of various origin differ in a number of features.
Vypotnye P., connected with an acute pneumonia, are caused by involvement of a visceral pleura in a zone of pneumonic infiltration. The so-called parapneumonic P. which is observed in the middle of inflammatory process in lungs is usually characterized by a small exudate. Such P.'s signs often mask symptomatology of pneumonia, and existence of an exudate is established, hl. obr. radiological. At nizhnedolevy pneumonia identification of an exudate against the background of pulmonary infiltration is represented extremely difficult therefore parapneumonic vypotny P. in a large number of cases is not diagnosed that leads to the subsequent suppuration of an exudate and so-called metapneumonic P.'s development, or a metapneumonic empyema of a pleura. At a favorable current the parapneumonic exudate rezorbirutsya rather quickly, usually to a rassasyvaniye of pneumonic infiltration, leaving behind pleural unions.
The wedge, tubercular P.'s picture is characterized by a big variety and depends on age of the patient and a condition of its organism, degree of a sensitization, existence of other displays of tuberculosis, character morfol, changes in a pleura, character and quantity of an exudate, localization of the Item. Depending on these factors the wedge, options tubercular P. allocate the following: allergic, perifokalny actually tuberculosis of a pleura.
Allergic tubercular P. arises at patients with primary tuberculosis at fresh infection or hron, the course of primary tuberculosis infection (see Tuberculosis of a respiratory organs). As a rule, at such patients the hypersensitivity to tuberculine which is shown the expressed tuberkulinovy reactions is noted. The disease is characterized by the acute beginning with temperature increase to 38 ° and more. Even at treatment by specific pharmaceuticals elevated temperature keeps 10 — 15 days. During this period the exudate quickly collects, tachycardia, short wind, stitches develop, to-rye rather quickly disappear. The exudate has serous character, at early stages sometimes serous and hemorrhagic. In an exudate find a large number of lymphocytes, sometimes eosinophils. Mycobacteria in an exudate, as a rule, are not found. Rassasyvaniye of an exudate occurs within a month and even quicker. However at accumulation of a large amount of liquid in a pleural cavity its resorption can be slowed down. In blood the eosinophilia, acceleration of ROE are quite often noted.
Except P., at primary tuberculosis at patients also other manifestations connected with giperergichesky reactivity can be noted: phlyctenas (see), a knotty erythema (see. Erythema knotty ), polyarthritis (see). According to B. M. Khmelnytsky, M. G. Ivanova, to A. E. Rab cinchona, these phenomena can precede P., appear along with it, develop several days later after a rassasyvaniye of an exudate or in more remote period.
Sometimes allergic P. arises prituberkulezny defeat tracheobronchial limf. nodes or primary tubercular complex. In these cases the wedge, a picture of a disease is defined not only by P., but also other displays of primary tuberculosis. In process of P.'s elimination the condition of bol*ny improves, however clinicoradiological manifestations of the available tubercular process remain. At TB patients with defeat tracheobronchial limf, nodes, proceeding with scanty symptomatology, vypotny P. is the brightest the wedge, display of a disease.
Perifocal tubercular P., as a rule, is result of involvement in inflammatory process of a visceral pleura from subplevralno the located tuberculous focuses and infiltrates. According to V. A. Ravich-Shcherbo, also long P. at TB patients tracheobronchial limf, nodes belong to perifocal P.
Unlike allergic perifocal P. proceeds against the background of a moderate general sensitization, but at the same time there is «a local hyperergy» of a pleura causing P. U development many patients perifocal P. has fibrinous or serofibrinous character. In this case accumulation of a large number of an exudate in a pleural cavity does not happen. The item proceeds as adhesive plastic process with formation of pleural stratifications (shvart). Wedge, such P.'s manifestations scanty, at patients are noted stethalgias, shortening of a percussion sound or more expressed obtusion over area of defeat, a pleural rub can be defined. At rentgenol, a research define pleural stratifications in the relevant department of a pleural cavity. At a pleurocentesis at such patients the exudate does not manage to be taken, there can sometimes be aspirirovano a small amount of serous liquid. Such P.'s current torpid and long, at a number of patients a disease has recurrent character.
Sometimes perifocal P. proceeds with accumulation of a serous exudate. The wedge, a picture of a disease is characterized by the acute or subacute beginning. Development of a symptom complex, typical for vypotny P., is noted. However the elevated temperature, perspiration, tachycardia and other phenomena of intoxication keep longer time, than at patients with allergic tubercular P. (3 — 4 weeks and more). The exudate remains in a pleural cavity within 4 — 6 weeks, after aspiration tends to accumulation. In cellular structure of an exudate lymphocytes prevail; mycobacteria, as a rule, do not come to light. In the subsequent the exudate rezorbirutsya, leaving behind pleural stratifications, to-rye can is long to remain and lead to restriction of mobility of a diaphragm, formation of a fibrothorax of which reduction of volume of a thorax, narrowing of intercostal spaces, retraction over - and subclavial poles, the shift of a trachea towards defeat is characteristic. All this leads to moderate dysfunction of breath.
It is difficult to reveal changes in lungs in the presence of perifocal tubercular P. Therefore rentgenol, the research of a respiratory organs should be made immediately after full evacuation of liquid. At the limited pulmonary process which is localized subplevralno, its identification even at a careful rentgenol, a research using a tomography can be difficult.
Tuberculosis of a pleura is characterized by multiple dissimination with formation of small, is sometimes lovely-liarnogo like the centers on a pleura, the single large centers with elements of a caseous necrosis or extensive caseous and necrotic reaction. The specified changes of a pleura are followed by the expressed exudative reaction of a pleura. The combination of tuberculosis of a pleura to other displays of tuberculosis and, first of all, with a pulmonary tuberculosis is possible.
The disease begins sharply or subacutely (at certain patients perhaps oligosymptomatic development). Body temperature increases. In blood the deviation to the left, a lymphopenia, sometimes a moderate leukocytosis, acceleration of ROE are observed. Symptoms of intoxication at patients keep is long and are liquidated in the course of treatment on average in 2 — 3 months at the «isolated» pleurisy. In cases of a combination of P. to other displays of tuberculosis duration of a disease is defined by dynamics of the last.
At a bystry obliteration of a pleural cavity fluid accumulation stops, occurs its gradual резорбция^ on a pleura there are fibrinous stratifications. At a large number of the exudate which collected in a pleural cavity and progressing of a caseous necrosis of a pleura transition of a serous exudate to purulent is possible.
The item at embolic heart attacks of lungs (see) or the so-called heart attack-pnemoniyakh is caused by reaction of a pleura to the subpleural center of a hemorrhagic necrosis in pulmonary fabric (aseptic or with the subsequent accession of an infection). In the first days after a heart attack the exudate has fibrinous character and is followed by the expressed pain syndrome. Further emergence of a serous exudate of often hemorrhagic character matches reduction or disappearance of pains. The exudate often happens scanty and hardly is defined by physical methods. Is not followed Vypotna P. at a heart attack of a lung by the expressed clinical symptoms. At some patients periodically arising hemorrhagic pleural exudate by the only display of a repeated heart attack of pulmonary fabric as a result of small embolisms at it is hidden the proceeding phlebothromboses and is a harbinger of such terrible complication as a massive embolism pulmonary artery (see).
Rheumatic P. usually complicates the heavy course of rheumatism at children's and youthful age and develops in time of the rheumatic attack. Quite often at the same time or consistently both pleural cavities are surprised. After the short-term period of dry P. there is an accumulation of small, is more rare than a significant amount of an exudate. Under the influence of antirheumatic therapy, and sometimes independently the exudate resolves within several days. When the rheumatic attack proceeds against the background of heart failure, in a pleural cavity the massive exudate can accumulate that causes the corresponding disorders of function of bodies of a chest cavity. Sometimes rheumatic P. is combined with the exudative pericardis which is making heavier a condition of the patient.
The item at other collagenic diseases quite often accompanies an aggravation patol, process, a wedge, its manifestations at the same time quite scanty. In some cases serous or seroznofibrinozny P. can be the only manifestation collagenose for a long time. Most often P. is observed at a system lupus erythematosus, is slightly more rare — at other collagenic diseases. Small stethalgias, bilateral localization and the scanty exudate rich with fibrin, chronic, sometimes a recurrent current are characteristic of this P. After a rassasyvaniye of an exudate massive unions are formed. At system to a lupus erythematosus (see) in an exudate it is possible to find so-called lupoid little bodies that allows to specify the diagnosis of a disease.
The item of tumoral genesis is most often observed at pleurogenic dissimination of cancer of lung, mesothelioma of a pleura, malignant tumors intrathoracic limf, nodes (a lymphosarcoma, a lymphogranulomatosis), at innidiation on a pleura of cancer of mammary glands, etc. Often pleural exudate appears earlier, than the main localization of a tumor is distinguished. At primary mesothelioma of a pleura of P. is the main display of a disease. For P. of tumoral genesis pains, sometimes very intensive in the field of the struck half of a thorax, not always accurately connected with breath and usually not disappearing at accumulation of an exudate are typical. Massive exudation often leads to disorders of breath and blood circulation. Temperature reaction, as a rule, is absent. The type of the exudate received at a puncture can be various. If blockade limf, ways in a root of a lung and a mediastinum is the reason of exudation, liquid can be serous, sometimes a lymph, muddy from impurity. At a direct injury of a pleura (a carcinomatosis, mesothelioma) the exudate usually happens hemorrhagic. At repeated punctures the exudate gradually loses hemorrhagic character. In process of an obliteration of a pleural cavity exudation can stop. If the nature of an exudate is not clear, it is necessary to make careful rentgenol, a research of lungs after full evacuation of liquid. At the same time sometimes it is possible to reveal a tumor of a lung or a mediastinum. The diagnosis can be confirmed bronkhol. research. Multiple nodes preferential on a parietal pleura are characteristic of mesothelioma of a pleura. In an exudate find complexes of tumor cells, a large number of the erythrocytes including changed. At chyle exudates — the drops of neutral fat painted by Sudan. In some cases tumoral P.'s diagnosis can be specified with the help torakoskopiya (see) and plevrobiopsiya.
Vypotna purulent pleurisy (an empyema of a pleura) is one of vypotny P.'s types, however its wedge, manifestations in total create a syndrome, significantly different from a syndrome not purulent vypotny P.
Empiyema of a pleura most often is a complication of the inflammatory processes in a lung caused by pyogenic microflora (at pneumonia, abscess, gangrene of a lung) or mycobacteria of tuberculosis, the opened or closed injuries of a breast, and also operative measures on bodies of a chest cavity (lungs, heart, a gullet etc.). Regardless of an origin distinguish a simple empyema without the expressed destruction of pulmonary fabric and an empyema with destruction of pulmonary fabric. Expressiveness of destruction of pulmonary fabric has significant effect on the result of treatment.
The wedge, a picture of a disease at most of patients is characterized by heavy intoxication, high temperature (to 38 — 39 ° above), night sweats, weakness, weight reduction (weight) of a body, pallor, tachycardia.
Gradually an asthma develops, there can be dry cough, stitches. In blood the lymphopenia, neutrophylic shift to the left, a moderate or high leukocytosis, ROE to 40 — 60 mm an hour are noted.
At an uncured empyema of a pleura of the patient can die from the progressing purulent intoxication and disorders of breath. In case of purulent destruction of fabrics there can be a break and emptying of pus through a bronchial tree or through a chest wall (so-called empyema necessitatis). If after operational opening of a cavity of an empyema and evacuation of pus the conditions promoting a raspravleniye of a lung and an union of a visceral and parietal pleura are not created the empyema of a pleura forms hron. At a delay of evacuation of pus through fistulas as a result of full or partial healing of the last there is an aggravation of process which is followed by increase of purulent intoxication, temperature increase and deterioration in the general condition of the patient.
At the small volume the sacculated residual cavity and free outflow suppurating a condition of the patient can be satisfactory throughout a long time, and existence of fistula and this or that extent of restriction of respiratory function happen the only displays of a disease. However at the big sizes of a cavity of an empyema and frequent aggravations of process patients owing to purulent intoxication are gradually exhausted. The struck half of a thorax decreases in volume, intercostal spaces are narrowed, respiratory excursions of lungs are limited, appear dystrophic changes in parenchymatous bodies (an amyloidosis of bodies). In partially or completely fallen down lung irreversible fibrous changes (pleurogenic cirrhosis of a lung) develop, sometimes form bronchiectasias (see).
Purulent P. can proceed also without the expressed intoxication, so-called cold flow. At the same time only short wind, tachycardia, cyanosis are noted.
The empyema of a pleura connected with pneumonia is practically a synonym so-called metapnevmonichesko-go P. Klien, manifestations of such empyema usually begin in the period of permission of pneumonia or after approach of the seeming recovery. At the same time at the patient the pain in the corresponding half of a breast connected with breath appears or renews, the general state worsens, temperature which is characterized by big daily fluctuations increases. Sometimes there are oznoba, sweats, especially at night, there is asthma, tachycardia progresses, purulent intoxication accrues. The patient loses appetite, quickly grows thin, skin gets a yellowish and earthy shade. At a physical research symptoms of accumulation of an exudate in a pleural cavity which volume gradually increases come to light. Morbidity in the corresponding mezhreberye is sometimes observed. At a blood analysis come to light the accruing hypochromia anemia, a leukocytosis with a considerable deviation to the left, toxic granularity of neutrophils. In urine protein is found, and at a long current of an empyema — cylinders. At a pleurocentesis receive muddy liquid or pus. Crops of an exudate allow to specify an etiology and to define sensitivity of the activator to antibacterial agents.
The empyema complicating abscess of a lung in most cases results from break of an abscess in a pleural cavity and quite often is followed by education pyopneumothorax (see).
At gangrene and gangrenous abscess of a lung the putrefactive empyema quite often develops; the exudate at the same time of dirty-gray color, fetid, contains putrefactive microflora in various associations. Intoxication in these cases happens especially heavy.
Purulent tubercular P. develops at a widespread caseous necrosis of a pleura owing to progressing and disintegration of the large centers, at a subpleural arrangement of a cavity.
Purulent P. after operation on bodies of a chest cavity, most often on lungs, is connected with massive infection of a pleural cavity during operation, napr, during the emptying of an intra pulmonary abscess in a pleural cavity. Besides, P.'s emergence depends on that, how fast and fully it is possible to straighten a lung or the remained its part after operation since long existence of a residual pleural cavity which contains an exudate or blood often leads to development of an empyema even at the minimum microbic pollution.
Early recognition of a postoperative empyema of a pleura is complicated since signs of a complication mask the symptoms which are observed at an uncomplicated postoperative current (pains in the field of operation, temperature increase, change of blood etc.). Only dynamic overseeing by a condition of the patient, his temperature, retests of blood, systematic rentgenol, control and obligatory pleurocenteses at any suspicion on accumulation of liquid of a pleural cavity with tsitol, and bacterial, a research of punctate allow to distinguish the beginning postoperative empyema in time.
The empyema of a pleura at injuries of a breast is connected with infection of a pleural cavity and usually develops in cases when in the course of treatment it is not possible to straighten timely a lung and to liquidate arisen at an injury pheumothorax (see) and hemothorax (see). Elimination of a hemothorax by means of a puncture is at a loss if blood in a pleural cavity is in a type of a massive clot (the curtailed hemothorax). Diagnosis of the empyemas of a pleura connected with an injury is carried out by the same principles, as diagnosis of postoperative empyemas.
the Diagnosis of pleurisy is based on data of the anamnesis, features a wedge, currents, and also this physical, laboratory, rentgenol, and other methods of a research.
At vypotny P. the major diagnostic method is pleurocentesis (see). The purpose of a puncture, on the one hand, final confirmation of accumulation of liquid in a pleural cavity, and with another — a research of this liquid that has great diagnostic value. At considerable free exudates the puncture is carried out, as a rule, in the seventh or eighth mezhreberye on the back axillary line. At exudates, sacculated and small on volume, the place for a puncture is defined at a multiaxial rentgenol, raying. After receiving punctate estimate its outward, color, a consistence, quantity, and then subject to a careful laboratory research (determination of specific weight, protein, microscopic examination of a deposit, bacterial, a research etc.). Specific weight higher than 1,016, protein content in it more than 3%, positive test of Rivalta is characteristic of an inflammatory exudate (exudate) (see. Rivalta test ).
Crops of serous and serous and hemorrhagic exudates at P. on usual environments most often yield a negative take. Growth of pyogenic microflora is usually observed at development of an empyema of a pleura. The tubercular nature of an exudate it is possible to establish at crops it on special environments or at infection of Guinea pigs, but in these cases affirmative answer is possible to receive in a month and more.
Results tsitol, researches of a deposit of punctate are not always specific to vypotny P. of this or that origin. At the beginning of a disease in draft neutrophils in most cases prevail, to-rye in process of stabilization and subsiding of process are replaced with mononuclear cells. Gradual increase of number of neutrophils and increase in number among them the deformed and destroyed cells, as a rule, speaks about serofibrinous P.'s transition to purulent. A large number of eosinophils testifies to allergic character of P. in cases of the simultaneous expressed eosinophilia of blood. Dominance in the draft of cells of a desquamated pleural mesothelium at a small amount of leukocytes is considered more characteristic of transudate, than for exudate.
At last, at P. of tumoral genesis in punctate in most cases find atypical tumor cells.
Essential value in specification of the diagnosis of some forms P. plays torakoskopiya (see), carried out after evacuation of an exudate and introduction to a pleural cavity of air. Especially informative this research appears at implementation via the thoracoscope of a biopsy patholologically of the changed sites of a pleura in which at microscopic examination it is possible to reveal tubercular, tumoral and other changes.
Rentgenol, a research allows to establish not only existence, but also the origin of P. which in most cases is a secondary disease is frequent.
The basic rentgenol, method at suspicion on P. is multiprojective Polyposition research (see). In addition make the so-called rigid or super-exhibited pictures, and also tomography (see), plevrografiya (see), bronchography (see), an angiography of lungs (see. Angiopulmonografiya ).
The main objective rentgenol, researches is identification of a free exudate in a pleural cavity.
At the correct technique of a research it is possible to reveal an exudate even in number of 100 ml. It is established that liquid in a pleural cavity accumulates a thin coat in the beginning between a visceral and diaphragmal pleura where there is the most low pressure. Here about 500 ml of liquid can be located, at the same time costal and phrenic sine a long time are represented free. Rentgenol. the picture in these cases approaches normal. At an orthoposition, however, it is possible to note higher arrangement of a shadow of a diaphragm on the party of the accumulated exudate as contours of the upper bound of liquid precisely repeat a configuration of a diaphragm. Sometimes at the same time the change of a configuration of a shadow of a diaphragm which is expressed that on border between average and outside thirds of a dome of a diaphragm there is an angular deformation in a form reminding a hump which is formed as a result of more steep course of outside department of a diaphragm can be observed. Besides, the excursion of a diaphragm on the party of accumulation of liquid is a little reduced. If the pleural exudate is formed at the left, the distance between an air bubble of a stomach and foundation of the pulmonary field increases. This shadow strip which width normal does not exceed 0,5 cm can increase in sizes twice and more.
At accumulation of large amounts of liquid when the last does not find room to a .mezhd a visceral and diaphragmal pleura, it passes into pleural sine. In these cases the amount of liquid in a pleural cavity usually exceeds 500 ml; what located border of an exudate above, this quantity is more than subjects. At transfer of the patient in horizontal position liquid spreads and transparency of the respective pulmonary field is represented lowered, it is a so-called phenomenon of Lenk (see. Lenka phenomenon ). However at a small amount of liquid (less than 400 ml) in horizontal position on a trokhoskopa the positive phenomenon of Lenk since thickness of a nappe, the thorax spreading along all back wall, happens insufficient in order that the difference in transparency of pulmonary fields appeared not always allows to get transfer of the patient. The best way of identification of an exudate in a pleural cavity is the research in lateroposition on the corresponding side. At the same time liquid spreads along costal edge, and on width of the formed pristenochny tape-like shadow it is possible to judge quantity of an exudate (fig. 3). If liquid is not enough, it is reasonable to make a picture in an expiratory phase; at the same time the strip of blackout becomes wider owing to raising of a dome of a diaphragm. Accumulation of very large amount of liquid in a pleural cavity leads to massive blackout of all pulmonary field («total pleurisy») and sharp shift of a median shadow to the opposite side (fig. 4).
Character of a pleural exudate (serous, hemorrhagic, purulent) does not influence patterns of accumulation and distribution of an exudate in a pleural cavity. It is only possible to note that dense pus moves at change of position of the patient slightly more slowly. After a rassasyvaniye of an exudate often there are pleural imposings, the obliterated sine, sites of calcification of a pleura (fig. 5) sometimes come to light. The last are observed more often after an empyema or a hemothorax.
The sacculated P. of various localization have characteristic rentgenol. picture. Pristenochnye P. are characterized by existence on the roentgenogram of the semi-spindle-shaped shadow which is widely adjoining costal edge. The corners formed by a contour of a shadow with a chest wall, stupid (fig. 6). Good visibility in one of projections and an indistinct picture in a perpendicular projection is typical for pristenochny P.'s shadow. At breath the shadow of a pristenochny exudate is displaced on costal type. Apical P. has the clear arc-shaped lower bound well visible in all projections, other contours of a shadow merge with surrounding fabrics. The shadow sacculated phrenic P. merges with a shadow of a diaphragm from which it can not always be otdifferentsirovat. Paramediasti-nalny P. merges with a median shadow, causing its expansion. It can be upper or lower, front or back. In a direct projection the outside contour of a paramediastinal exudate is well visible; he is usually straightforward that allows to distinguish P. from a politsiili-chesky contour increased limf, nodes of a mediastinum. Interlobar P. has the form of a biconvex lens. In a direct projection the exudate sacculated in a horizontal crack of the right lung is well visible. At the same time lower contour of a shadow of an exudate usually more convex, than upper. The exudates sacculated in slanting cracks of lungs in a direct projection are badly visible. The research in the provision of a hyperlordosis is applied to the best identification of small exudates of this localization (situation on Fleyshnera); at the same time the direction of slanting cracks becomes close to horizontal that leads to improvement of visibility of an exudate. Interlobar exudates are much better visible in a side projection. The fact that the lower pole of a lenticular shadow of an interlobar exudate is usually wider, than upper (fig. 7) attracts attention. In most cases the exudate is sacculated in lower parts of slanting cracks; at bed patients it can be sacculated also in upper parts. In a direct projection the interlobar exudate which is especially located in a horizontal crack can have rounded shape and imitate intra-pulmonary educations, in particular peripheral cancer; however such symptoms as the linear strips of a reinforced pleura departing from edges of a shadow of an exudate, a thickening of a pleura in the next departments and, the main thing, a lenticular form of an exudate in side pictures and tomograms, allow to carry out differential diagnosis.
If in the presence of an exudate air (as a result of a puncture gets into a pleural cavity or at damage of pulmonary fabric, napr, at a rupture of superficially located air-vessels), there is a picture of a pneumopleuritis or a hydropneumothorax. It is characterized by existence of the horizontal border separating a shadow of an exudate from an air bubble. The similar picture can be observed also at encysted effusion.
Depending on P.'s outcome the picture is observed various rentgenol. In one cases the exudate completely resolves, and only the reinforced pleura demonstrates the former process. At longer current, especially after purulent P., the partial or full obliteration of a pleural cavity, a prelum of a lung, sharp shift of bodies of a mediastinum towards defeat, high standing and fixing of a dome of a diaphragm is quite often noted.
Treatment at dry P. first of all is directed on that patol, process which was the reason of the Item. If it is not possible to identify primary process, and P. proceeds with dominance of a pain syndrome and ukhmeren-but the expressed general reaction, hospitalization is in most cases optional. To the patient appoint bed or a semi-bed-ny the mode depending on expressiveness of symptomatology. During this period use of anesthetics, the antiinflammatory and hyposensibilizing means in usual dosages is recommended. In a certain measure such methods of treatment of dry P. as the warming compresses with hard bandaging of lower parts of a thorax, banks, greasing of skin on the party of defeat of 5% spirit solution of iodine kept the value.
Treatment vypotny (serous and serofibrinous) is also directed to P. first of all to elimination of the basic disease which was complicated by a pleural exudate. At establishment of the diagnosis of vypotny P. patients, as a rule, are subject to hospitalization for identification of a basic disease and purpose of the corresponding treatment.
Depending on weight of a state and expressiveness of intoxication the bed or semi-bed rest is appointed. By means of the mode, the diets hyposensibilizing and anti-inflammatory drugs impact on pathogenetic mechanisms of the general and local reactivity of an organism for the purpose of delay or suspension of accumulation of a pleural exudate is carried out.
In the period of accumulation of an exudate the diet with restriction of water, salts and carbohydrates is recommended. From pharmaceuticals widely apply Dimedrol, sodium salicylate, acetilsalicylic to - that, drugs of a pyrazolon row, Calcii chloridum, in the presence of indications — corticosteroid hormones (see. Corticosteroids ). Hormonal means at P. of the infectious and allergic nature apply under protection of antibacterial agents.
By means of a pleurocentesis make evacuation of an exudate for the purpose of prevention of an empyema of a pleura and for elimination of a prelum a massive exudate of bodies of a chest cavity.
Real danger from the point of view of a possibility of development of an empyema is constituted by reactive exudates at nonspecific pneumonia (parapneumonic P.), the pleural exudates connected with an injury or intrapleural operative measures at which the exudate usually contains big or smaller impurity of blood. In these cases even small amounts of liquid delete by means of a puncture, to-ruyu complete preventive administration of antibacterial agents. It is not obligatory to delete the serous exudate moderated on volume.
At bystry accumulation of an exudate and disorder of breath and blood circulation the unloading pleurocentesis is vital. If the patient badly transfers single-step evacuation of all exudate which quantity can reach two and more liters, at the first puncture only a part of liquid is evacuated. Next day the puncture repeats, and the exudate is sucked away as much as possible. Further unloading punctures quite often should be repeated. At removal of liquid and intrapleural introduction of a hydrocortisone is long not resolving exudates accelerates recovery and limits development massive shvart.
After subsiding of the acute phenomena, in the period of a rassasyvaniye of an exudate the treatment directed to restriction of formation of sra-pkheniye and recovery of function of bodies of a chest cavity is reasonable. Respiratory gymnastics, manual and vibration massage, use of ultrasonic therapy are recommended.
After vypotny P.'s treatment patients shall be a long time under dispensary observation in specialized institution.
Purulent P.'s treatment (empyema of a pleura) shall be the earliest, purposeful and rather intensive that allows to achieve bystry effect and to reduce number hron, empyemas and lethal outcomes. Patients with an empyema shall be hospitalized in the surgical departments having experience in treatment of diseases of lungs and a pleura. Medical measures at an acute empyema are divided into the general and local. Carry the mode to measures of the general order (in the acute period bed) and food, protein-rich and vitamins. At highly in a fever patients with symptoms of purulent intoxication, the measures directed to fight against an infection are of great importance (the antibacterial agents which are picked up according to sensitivity of the microflora sowed from a pleural cavity and also the means increasing specific and nonspecific resistance of an organism — polyglobulins, hyperimmune plasma, etc.). Serves as an obligatory component of treatment of empyemas of a pleura auxiliary parenteral food (see), shown at extreme degrees it is purulent - resorptive fever and is purulent - resorptive exhaustion. Auxiliary parenteral food is carried out through an upper vena cava by a puncture of a subclavial vein. At the same time daily enter protein hydrolyzates, 50% solution of glucose, antagonists of Aldosteronum, drugs of vitamins, solution of calcium chloride, plasma, anabolic steroids (retabolil).
Protein hydrolyzates enter slowly for increase in nutritious effect and prevention of local and general reactions. Infusional therapy shall be carried out under control of systematic scoping of the circulating blood and its components, and also proteins and electrolytes of plasma.
Topical treatment of an empyema of a pleura has paramount value. Its basis is the sanitation of a pleural cavity which is carried out in one way or another depending on features and a phase of a current of an empyema. At acute empyemas of a pleura apply the following methods of sanitation of a pleural cavity: pleurocenteses, drainage with continuous active aspiration, constant or fractional washing (lavage) of a pleural cavity.
Treatment acute purulent P. by means of pleurocenteses (see) is shown at empyemas which cavity is not reported with the atmosphere (through respiratory tracts or fistulas of a chest wall). At total (subtotal) empyemas the puncture is carried out in the typical place — in 7 — 8 mezhreberye on the back axillary line. At limited empyemas the place for a puncture is chosen during a multiaxial X-ray analysis so that the puncture was made 3 — 5 cm above the assumed bottom of a cavity of an empyema. The purpose of a puncture is evacuation of pus with the subsequent bacterial, and tsitol, its research, and also trial aspiration for clarification of opportunities of a lung to a raspravleniye. Before a puncture careful assessment anamnestic, physical and rentgenol, data because the puncture of an echinococcal cyst or contents of the phrenic hernia taken for a pyopneumothorax will lead to complications is necessary. All extracted pus without restriction of quantity is evacuated. Then the needle is connected to the manometer for measurement of the intrapleural pressure which is carefully registered for the purpose of recognition of bronchopleural fistula. The first puncture comes to an end with intrapleural administration of solution of a furagin or dioxidin, antibacterial agents of a broad spectrum of activity. V. I. Struchkov with sotr. (1967) recommend to add to them fermental means of type of trypsin, chymotrypsin, etc., to-rye promote clarification of walls of an empyemic cavity. After the bacterial analysis of a pleural exudate the puncture is finished with introduction to a pleural cavity of the antibiotic dissolved in the small volume of liquid which is picked up according to sensitivity of the allocated microflora. Introduction to a pleural cavity of antibiotics is most reasonable only after as a result of preliminary sanitation are cleared by antiseptic agents of a wall of a cavity and the exudate will become serous and purulent, without flakes of fibrin. Frequent systematic, quite often daily, punctures shall be combined with washing of a cavity of an empyema antiseptic agents during which it is possible «to process» all walls, trying to obtain contact of wash liquid with crypts and lacunas of a dome of a cavity of an empyema. For this purpose the drop system can be used, through to-ruyu the washing-out warm liquid slowly it is filled in in a cavity (fig. 8). At dense pus proteolytic enzymes can be added to the washing-out liquid. During the first session the doctor, watching a condition of the patient, determines the volume of a cavity and painless rate of administration of liquid in it. After the maximum filling of a cavity the system of supply of the washing-out liquid is blocked. At the closed system of the patient turns on the right, left side, sits down, constantly changes situation all walls of a cavity were washed. After that wash liquid is removed. The session is repeated by two-three times, irrigating a cavity of an empyema depending on its volume of several liters of solution, aiming to wash out it to «pure water». After elimination of temperature, intoxication and disappearance of purulent character of an exudate intervals between punctures can be increased. Punctures stop only after a full raspravleniye of a lung and an obliteration of a residual cavity. Repeated repeated punctures injure the patient, and, above all do not create conditions for constant depression in a cavity of an empyema that is necessary for a raspravleniye of pulmonary fabric. Accumulation of pus in intervals between punctures interferes with full elimination of a resorption of waste products of microbes and disintegration of fabrics. Therefore at widespread and total empyemas resort to to aspiration drainage (see). Drainage is shown also in the absence of effect after 3 — 4 repeated punctures. For a drainage use a tube from silicone rubber which does not possess irritant action on soft tissues of a chest wall (fig. 9). The drainage connects to aspiration system in which depression is supported with the help aspirators (see), a water-jet suction or the centralized vacuum system. The passive valve drainage across Byulau cannot be considered as an effective method and is used only at impossibility to provide constant vacuum (see Byulau a drainage). Aspiration drainage is carried out continuously, round the clock. Speed of aspiration is established so that in a pleural cavity negative pressure was supported that creates conditions for optimum outflow of pus, raspravleniye partially or completely fallen down lung and an obliteration of a pleural cavity. At long finding of a silicon drainage tube in soft tissues the drainage channel can be infected and suppurate, despite a daily antiseptic toilet of surrounding skin.
In this case the drainage is taken, the purulent channel is excised all the way down with imposing of deaf, rare vertical P-shaped mylar seams a fine end. Nearby, slightly higher or below, but surely enter a new drainage into projections of bottom edge of a cavity of an empyema. If necessary carry out repeated 3 — 4-fold migration of a drainage.
At a heavy current of an acute empyema, in particular at postoperative empyemas when there is a danger of suppuration and discrepancy of a torakotomichesky wound, constant washing (lavage) of a cavity of an empyema is shown by antiseptic solutions. In this case two tubes are entered into a cavity of an empyema by means of troakar, thick also thinner is closer to a bottom of a cavity in its verkhneperedny department. The thick tube, as well as at a method of continuous aspiration, connects to a vacuum system for continuous aspiration of liquid and air. Through a spaghetti from the system supplied with a dropper and a throttle clip in a pleural cavity after aspiration of pus solution of an antiseptic agent with addition in case of need of proteolytic enzymes (fig. 10) constantly kapelno moves. During the day moves to several liters of the solution which is constantly irrigating a pleural cavity which is aspirated together with an exudate. Lavage in a daily dose comes to an end with introduction of the antibiotics which are picked up for sensitivity.
Criteria of efficiency of sanitation of a cavity of an empyema is 3 — 4-fold negative bacterial. crops of pleural contents.
At a pyopneumothorax with wide bronchopleural fistulas full sanitation of a pleural cavity is complicated owing to a pelting of rinsing waters in bronchial tubes.
Upon transition of an empyema in hron, a form there is a stabilization of a collapse of a lung and therefore treatment hron, empyemas of a pleura can be only operational. Careful sanitation of a cavity of an empyema, and also use of the measures directed to strengthening of the general condition of the patient and correction of the disturbances caused shall precede operation it is long the proceeding purulent process. The purpose of operation at hron, an empyema of a pleura is elimination of a purulent cavity in a pleura and a raspravleniye of a lung. These objectives can be achieved in two essentially various ways.
The first of them is mobilization of a chest wall over a cavity of an empyema to bring it into contact with the covered shvarty surface of the fallen-down lung and thus to provide conditions for an obliteration of a cavity and elimination of purulent process.
Interventions of this kind carry the name thoracoplasties (see). Methods at which the cavity of an empyema is filled with a muscular rag on the feeding leg (myoplasty) are based on the same principle.
The second possible way of elimination of a cavity of an empyema consists in release of a lung from the rigid visceral shvarta covering it and creation of conditions for its raspravleniye.
This method received the name decortications of a lung (see) which is in most cases carried out with simultaneous removal of a parietal pleura or all walls of a cavity of an empyema — pleurectomy (see).
This method is shown at big residual cavities and availability of the full-fledged pulmonary fabric capable to fill a pleural cavity after removal shvart. Besides, the pulmonary fabric destroyed by purulent process demands an adequate resection — a pleurolobectomy, pleurosegmentectomies are more rare (see. Lobectomy , Segmentectomy ) in combination with a pleurectomy and a decortication of the rest of a lung. Such operations present considerable technical difficulties and are connected with danger of intraoperative bleeding, leakage of the rests of slight, postoperative suppuration of a wound and the operated half of a chest cavity.
For prevention of infection of the pleural cavity deprived of a parietal pleura in the early postoperative period through a drainage the directed its washing by antiseptic agents with the subsequent introduction of antibiotics is carried out.
The open method of treatment of a cavity of an empyema is not applied. Vishnevsky's operation — Connors, consisting in an oily-balsamic tamponade of a cavity of an empyema after a wide resection of edges, is almost not used now. In V. V. Podzolov (1967) modification the open closed method of treatment (a pleurotomy, sanitation by ointment tampons within 3 — 4 weeks, a deaf secondary seam and puncture aspi-ratsionnaya sanitation of a cavity) is occasionally used at treatment of empyemas of small volume at the weakened and elderly patients.
In the postoperative period careful overseeing by an adequate reekspansiya of a lung, and also prevention of suppuration of post-resection cavities is required.
Physiotherapeutic methods of treatment of P. include both natural, and artificial physical factors. At P. of a tubercular etiology the physical therapy is applied in combination with treatment by antituberculous remedies. In the acute period of dry P. apply daily radiation of a thorax on the party of defeat by a lamp sollyuks Minin's pl (see. Phototherapy ). Influence uv radiation in slaboeritemny doses a projection of the center of an inflammation (see. Ultraviolet radiation ). Paraffin or ozokeritovy applications are shown (see. Paraffin therapy , Ozoceritotherapy ). After normalization of temperature make an electrophoresis of calcium, iodine, salicylates (see. Electrophoresis , medicinal), having an active electrode on a projection of the center of an inflammation, and the second — on the opposite side of a thorax. Procedures are carried out daily or every other day. Appoint electric field of UVCh to the center of an inflammation (see UVCh-therapy), DMV-therapy (see. Microwave therapy), and also ultrasonic therapy (see). In the recovery period apply hydrotherapeutic procedures and balneoprotsedura. Sanatorium treatment of patients with dry P. is shown in resorts of the Southern coast of the Crimea and in arid steppe climate regardless of an etiology of the Item.
At vypotny P. in the acute period appoint radiation a lamp sollyuks or Minina, at first every other day, and then daily. For the purpose of increase in defense reactions of an organism appoint the general uv radiation of 1 — 2 time a week. Use also paraffin and ozokeritovy applications. At elimination of the acute phenomena and normalization of temperature appoint electric field of UVCh. At the accompanying bronchitis apply inductothermy (see), having the inductor disk on the struck half of a thorax. In the period of a rassasyvaniye apply a calcium-iodine-electrophoresis or Pancreatinum electrophoresis on the party of defeat. Procedures are carried out in the beginning every other day, and then daily. In the recovery period apply iodine electrophoresis daily or every other day, at the same time effective use of proteolytic enzymes (trypsin, chemical opsin, chymotrypsin), and also ultrasound on a zone of defeat. Sanatorium treatment is carried out in areas with a warm arid climate, in a forest zone and in local profilnzirovanny sanatoria.
The physiotherapy exercises play an important role in complex treatment of the Item. The applied means of LFK (physical. exercises, special breathing exercises, massage) stimulate krovo-and a lymphokinesis that promotes elimination of inflammatory changes in a pleural cavity, accelerate absorption of an exudate, prevent formation of pleural commissures, recover breath and prepare cardiovascular system for the increasing exercise stresses. LFK is appointed, as a rule, in a stage of recovery when the phenomena of an inflammation of a pleura abate, body temperature decreases to normal or subfebrile, the quantity of an exudate decreases, pains, cough decrease or disappear, the general condition of the patient improves.
During the occupations remedial gymnastics the patients who are on a bed rest carry out all movements in initial positions lying on spin or on a sick side. Protozoa physical are carried out. exercises for small and average joints of extremities, breath at the same time does not go deep. After several occupations the initial position is allowed sitting, exercises for a trunk, but with a small amplitude of movements are added. Emergence of stethalgias indicates decrease in load the need. Time of occupation of 8 — 10 minutes, speed slow. Upon transition of the patient to the ward motive mode the remedial gymnastics is applied in initial positions sitting and standing. Except the listed exercises inclinations and turns of a trunk with gradual deepening of breath are carried out. If exercises for a trunk do not cause pain in a breast, they can be combined with the movements of hands. Breathing exercises are done in a dorsal decubitus and on a healthy side that provides the strengthened excursion of the affected lung. Duration of occupation is 20 — 25 minutes, speed slow and average. On the free (training) motive mode widely use special physical. the exercises which are increasing mobility of a thorax and dragging out pleural commissures (turns and inclinations in the healthy party during a breath, use of gymnastic sticks, walls, benches, balls, etc.). It is necessary to apply as well the special breathing exercises strengthening function of breath it is preferential in lower parts of a thorax and the diaphragms developing mobility (breathing exercises with position of hands on the head or with lifting of hands during a breath). At occupations with children it is possible to include exercises for education of skill of a correct posture, the outdoor games selected according to their age and motive features in gradually increasing dosage at this time. Duration of occupation is 30 — 40 minutes, speed average. During the occupations remedial gymnastics it is necessary to consider age, associated diseases, the general state, functionality of the patient. After an extract from hospital studies remedial gymnastics are recommended to be continued on an outpatient basis. Besides, walks in the fresh air, walking on skis are desirable, swimming, sports, etc.
Dry and vypotny not purulent P. practically never define the forecast of a basic disease which complication they are. Purulent P. sharply burden a condition of patients and have a certain predictive value though a role in the failure of actually pleural suppuration and patol, process which was its reason it is not always easy to define. In general the forecast in the presence of an empyema of a pleura always should be considered serious as the lethality even during the use of modern methods of treatment, according to G. I. Lukomsky (1976), reaches 22%.
Prevention of pleurisy consists first of all in timely and correct treatment of the diseases which are complicated by inflammatory process in a pleura. Early recognition and evacuation from the pleural cavity of blood, air and an exudate promoting suppuration is the cornerstone of purulent P.' prevention. The prevention of postoperative empyemas is reached by a careful operational asepsis, good sealing of the remaining part of a lung, the correct processing of a stump of a bronchial tube and a bystry raspravleniye of pulmonary fabric after partial resections.
Features of pleurisy
Dry (fibrinous), and also vypotny not purulent P. at children occur at children seldom, and their wedge, current differs from that at adults a little. Before emergence of antibiotics purulent P. occurred at children often, proceeded hard and were followed by a high lethality. Among activators pneumococci and streptococci prevailed. Specific weight was high and tubercular P.
Odna from the main reasons for development of purulent P. in children are now staphylococcal pneumonia, the frequency of pleural complications at which fluctuates from 60 to 80%. In recent years along with staphylococcus in genesis it is purulent - destructive pneumonia and P. at children increase of a role of gram-negative microflora is noted (pyocyanic and colibacillus, proteas, a klebsiyell).
Tubercular P. occur at children seldom. P.'s development after operative measures on a lung, and also owing to perforation of a gullet is possible at disturbance of the equipment of an ezofagoskopiya, bougieurage. Can be the rare reasons of infection of a pleural cavity at children: a rupture of the inborn suppurated cysts, the getting wounds of a thorax, a puncture of a cyst or abscess in the absence of commissural otgranichitelny process in a pleura.
Suppurative process in a pleura practically always is secondary, i.e. the strengthened exudation in a pleural cavity precedes infection. At most of children owing to opening of superficial abscesses of a lung the pyopneumothorax develops (see). Severe forms of inflammatory process in a pleura, including a total empyema, an intense and not intense pyopneumothorax, meet at newborns and children of chest age more often and proceed the heavier, than the child is younger. 1 years are aged more senior tendency to an otgranicheniye of inflammatory process in a pleura is shown.
The wedge, a picture P. of a polimorfn also depends on a form of damage of a pleura, age of the child, premorbidal a background and other factors. The item usually develops against the background of heavy pneumonia and is followed by the aggravation of symptoms of the child caused by increase of symptoms of intoxication and respiratory frustration. At the same time body temperature, especially in evening and night hours increases, short wind and tachycardia progress, appetite worsens. Children of younger age can have a pristupoobrazny cough which is followed by concern. P.'s emergence at a part of patients masks abdominal pains, a delay of a chair or its increase, paresis of intestines, spasms, coma, the astmoidny phenomena.
The heaviest a wedge, a picture develops at a total empyema of a pleura. Symptoms of heavy intoxication in combination with the disorders of breath caused by a collapse of a lung, and also disturbance of a hemodynamics owing to the shift of a mediastinum are characteristic. The delimited (sacculated) purulent P.'s forms proceed less hard, however symptoms of intoxication and short wind can be rather expressed.
Children can have acute purulent P.'s current, long and chronic. At an acute current process comes to an end within 1,5 months, at long continues from 1,5 to 3 months. If purulent process in a pleura lasts more than 3 months and is followed by development of the rough fibrous capsule leading to a persistent collapse of a lung and deformation of a thorax, it is possible to speak about development hron, empyemas. The acute current at children is prevailing; as a rule, it is observed on the first year of life. At children 1 years are more senior more often the long current takes place. Purulent P.'s outcome in hron, an empyema occurs at children seldom, frequency does not exceed it 3 — 4%. From hron, empyemas it is necessary to distinguish residual air-vessels in a pleura (dry cavities) which are quite often found at a long current of the purulent Item. Their difference are: lack of signs of inertly current purulent process, lack of the progressing deformation of a thorax, spontaneous reduction of the sizes of cavities and their total disappearance within 2 — 4 months. In the analysis of a current of P. it is important to establish, there are no signs of development of sepsis. Its probability is highest at newborn children and children of chest age.
P. solving in diagnosis and its forms is the combination of a survey X-ray analysis (in two projections, in vertical position of the patient) with a diagnostic pleurocentesis (see). Initial stages of involvement of a pleura in inflammatory process radiological are characterized by emergence of a shadow of a reinforced pleura on the periphery of a lung. The beginning exudation gives a picture plashchevidny P.: the exudate is defined in the form of more or less wide strip of blackout which is located parakostalno, the costal and phrenic sine is darkened. In the easiest the krupnofokusny infiltrates taking a segment, group of segments or a lung lobe are defined. Less often in a zone of infiltrate it is possible to see the focal enlightenments reflecting destructive process. Timely diagnosis on stages of infiltrate or plashchevidny P. and intensive therapeutic treatment often promote the abortal course of process. However, if rentgenol, the research and adequate treatment are late or the last is inefficient, during the progressing of inflammatory process in a pleura more severe forms — a pyothorax and a pyopneumothorax develop. In their diagnosis and specification of a form there is also usually enough combination of survey roentgenograms and pleurocentesis. For diagnosis of the accompanying pathophysiological disturbances conduct the corresponding laboratory and functional researches.
Differential diagnosis is especially difficult at early stages of development of P. because of dominance of the general symptoms and existence at a part of the sick masking syndromes. The expressed respiratory frustration in these cases shall be a reason for an obligatory rentgenol, a research of bodies of a chest cavity. In doubtful cases resort to additional researches: to survey and a palpation of a stomach during medication sleep at suspicion of appendicitis, an ir-rigografiya with administration of air in a large intestine for an exception of invagination, a lumbar puncture at impossibility to exclude meningitis and so forth. It is necessary for an exception of tubercular nature of a disease careful izucheniyeepidemiol, the anamnesis, a wedge, pictures, results of tuberkulinovy tests and a research of an exudate.
Purulent P.'s treatment at children, just as at adults, consists of intensive general care and sanitation of local purulent process. Intensive therapeutic treatment includes first of all an antibioticotherapia and actions for fight with intoxication (see). The amount of the liquid entered intravenously kapelno is defined by age, expressiveness of toxicosis and an eksikoz. Introduction is carried out under control of a diuresis and if it is insufficient, diuretics are appointed. At children fight against a hyperthermia is of particular importance (see. Hyper thermal syndrome ). Necessary components of treatment are an oxygenotherapy (see. Oxygen therapy ), correction of metabolic acidosis (see), elimination of disturbances of electrolytic balance (hypopotassemia), fight against paresis of intestines, therapy of disturbances of cordial activity and microcirculation.
A powerful therapeutic factor is passive immunization (see) and the stimulating therapy (see). Active immunization in the acute period is less reasonable and proved in later terms at the sluggish, long course of process. Special attention shall be paid to food of patients, including parenteral.
Methods of sanitation of local purulent process are similar described at adults. Treatment by repeated pleurocenteses with evacuation of an exudate and washing of a cavity antibiotics and antiseptic agents reasonablly at plashchevidny P. the delimited forms of the purulent Item. This method can be applied and some patients with a total empyema have pleurae at which the exudate has no viscous consistence and after the first punctures the tendency to reduction of its accumulation in a pleural cavity is noted.
The main method of treatment of a total empyema of a pleura is aspiration drainage of a pleural cavity, a cut is applied also at inefficiency of treatment by punctures. In the course of treatment drainage, just as at adults, with success applies fractional or constant washing (lavage) of a pleural cavity.
At purulent P.'s complication there can be indications to operative measures on a lung and a pleura (see. Pyopneumothorax ).
The long-term results at the children who transferred purulent P. are favorable. However at a part of patients, especially if deep abscessing is the cornerstone of P.'s development, development hron, inflammatory process in a lung is possible. Such patients need dispensary observation.
Purulent P.'s prevention is connected with early diagnosis and adequate treatment of pneumonia and initial stages of the Item.
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H. B. Putov; B. M. Bogolyubov (fizioter), B. I. Geraskin (it is put. hir.), I. K. Yesipova (stalemate. An.), V. P. Illarionov (to lay down. physical.), G. I. Lukomsky (hir.), L. S. Rozenshtraukh (rents.), A. G. Homenko (ftiz.).