STOMACH

From Big Medical Encyclopedia

STOMACH [abdomen (PNA, JNA, BNA)] — the lower half of a trunk including an abdominal wall and an abdominal cavity.

== ANATOMY

==. above borders on a breast (see. Breast ), below on the line drawn from a pubic symphysis on inguinal folds to front upper awns of ileal bones, further on their crests and the basis of a sacrum — with a girdle of inferior extremity. Wall. consists of a lobby abdominal wall (see), limited right and left back axillary lines (lineae axillares post. dext, et sin.), a back abdominal wall, or a waist (see. Lumbar area ); upper wall. is diaphragm (see), lower — ileal poles (fossae iliacae) delimiting an entrance in small basin (see). Form Zh. is defined by a form of its front wall. Depending on width of a thorax and a basin are extreme a pear-shaped form Zh. with expansion from top to bottom (female type) or up (men's type). Transitional forms. are similar to an oval. To the specified extreme forms of a front wall there correspond forms of lumbar area: in the form of the correct trapeze with the basis from top to bottom (female type) or up (men's type). Position of bodies. does not correspond to its borders. Above a part of bodies is placed within borders of a thorax, and below — in a basin.

the Arrangement of bodies of a stomach (And — an anterior aspect, B — the back view): 1 — a projection of a diaphragm; 2 — a spleen; 3 — a stomach; 4 — a big epiploon; 5 — a cross colon; 6 — a small bowel; 7 — a projection of the descending colon; 8 — a sigmoid colon; R — a bladder; 10 — a projection of a rectum; 11 — a projection of a worm-shaped shoot; 12 — a caecum; 13 — the ascending colon; 14 — a gall bladder; 15 — a projection of the gatekeeper; 16 — a projection of the upper bound of a cross colon; 17 — a liver; 18 — the lower vena cava; 19 — an adrenal gland; 20 — a right kidney; 21 — a pancreas; 22 — a duodenum and its projection; 23 — the right ureter; 24 — a left ureter; 25 — a left kidney.
Fig. 1. The diagrammatic representation of sagittal cuts of the lower half of a trunk with age distinctions in topography of bodies of a stomach (on Valkera): and — the newborn; — the child of 1 year; in — the elderly person; 1 — a liver, 2 — a stomach, 3 — a cross colon.

In a cavity. bodies of digestive and urinogenital systems, large vessels and neuroplexes are located. Most bodies. has passive and active mobility. Passive mobility — the movement of bodies connected with the respiratory movements of a diaphragm and front abdominal wall, with change of position of a trunk and a palpation. Active mobility — the movements caused by performance fiziol. functions, napr, peristaltics. In connection with considerable mobility of bodies. their fixing on the place inherent to them is important. The fixing offices of bodies are their fascial cases, peritoneal sheaves, neurovascular legs; some bodies have an anatomic bed (e.g., a spleen, kidneys). The greatest value in fixing of bodies. plays intra belly pressure (see), depending on a tone of muscles of an abdominal wall. Weakening of a tone of muscles of a front abdominal wall leads to omission of bodies. — to a splanchnoptosia (see). Individual and age distinctions of position of bodies (fig. 1) are noted. Specific features of topography of bodies. (a bigger or smaller covering of bodies a peritoneum, the level of an arrangement, their syntopy) are caused by distinctions in a constitution and the course of process of an embryogenesis. At children and young people higher arrangement of bodies is noted, old men quite often have a splanchnoptosia. Therefore projection of bodies. on its walls (tsvetn. fig.) differs in big variability.

Blood supply. Organa Zh. are supplied with blood from branches of a ventral aorta. Feature of blood supply of bodies. — strongly developed collateral bed and a large number of a vascular anastomosis that facilitates compensation of a blood-groove at ischemic processes and is used at various reconstructive plastic surgeries. Outflow of blood from unpaired bodies comes through a portal vein in lower hollow, and from pair bodies and walls. — directly in the lower hollow. Within a cavity. there is multiple anastomosis between sources of the lower hollow and portal veins (see. Porto-caval anastomosis ).

Lymphokinesis. Outflow of a lymph from bodies. it is very difficult. There are multiple bonds between various groups limf, nodes owing to what ways of innidiation of malignant tumors and spread of an infection are various. The lymph from numerous limf, nodes of a cavity of a stomach gathers in the lumbar and intestinal trunks forming the tank of a chest channel (cisterna ductus thoracici), from a cut begins chest channel (see).

Innervation bodies. it is carried out by celiac neuroplex and its derivatives (aortal, top and bottom mesenteric, gastric, hepatic, renal and other textures). There are distinctions in sources of formation of neuroplexes of a cavity to Zh.Poety various options of localization of pains meet at patol, processes in an abdominal cavity.

EMBRYOLOGY

Development. and its bodies comes from all three germinal leaves. The endoderm creates epithelial structures of intestines, liver, pancreas. From a somatic mesoderm (mesoderma somaticum) there is laying of muscles of abdominal walls and a diaphragm. The Splankhnichesky mesoderm (mesoderma splanchnicum) creates smooth muscle covers of a digestive tract, the urinogenital device and vessels, and also a peritoneum. From an ectoderm the integument of a stomach and nervous educations develop.

Embryology of separate bodies of a stomach — see articles according to the name of bodies (e.g., Intestines , Liver etc.).

METHODS of the RESEARCH

Distinguish the general and private research Zh. The general research aims to study all complex of bodies and fabrics Zh. The private research provides studying of separate abdominal organs. The general research is always begun with inquiry of the patient to reveal his complaints. In the presence of complaints to pains in. it is necessary to find out their localization, character, intensity, irradiation, changes in dynamics and the reasons leading to developing of pains. Distinguish two types of pains: the somatic, resulting irritations of sensitive receptors of spinal nerves, and visceral which conductors are trunks of century of N of page. Visceral pains have no accurate localization and arise usually owing to a strong vermicular movement, a spasm of muscles of the central origin (colic) or ischemia of body at a spasm or obstruction of the feeding blood vessel. Somatic pains are localized, arise during the involvement in process of a peritoneum more often and usually are followed by tonic contraction of the corresponding belly muscles. At patol, processes in an abdominal cavity (peritoneal cavity) of pain have the mixed character, one type of pains can be replaced by another. E.g., at an acute appendicitis in the beginning pains of visceral type have no accurate localization or concentrate in epigastric area, and then, at distribution of inflammatory process on a parietal peritoneum, gain somatic character and are localized in the right ileal area. A wedge, the analysis of a source of pains in. is at a loss a large number of abdominal organs which closely adjoin to each other, abundance of neuroplexes, and also a variety of places and mechanisms of irritation.

At poll it is necessary to find out whether were available in the past of a disease of bodies. and whether the patient was exposed to any surgeries on an abdominal wall and in a cavity. The careful analysis of data, poll of the patient in many respects predetermines establishment of the correct diagnosis.

Fig. 2. A front surface of a stomach with network of expanded saphenas («the head of a jellyfish») at disturbance of outflow of blood on a portal vein.
Fig. 3. A front surface of a stomach with network of expanded saphenas (collateral hypodermic circulation) at the complicated krovoottok on the lower vena cava.
Fig. 4. Increase in the lower half of a stomach at the patient with a pyloric stenosis. The expanded, crowded and lowered stomach sticks out a wall of a stomach below a navel.
Fig. 5. Approximate superficial palpation of a stomach.
Fig. 6. Palpation of an anticardium of the upright patient.
Fig. 7. Deep palpation of a cross colon two hands.
Fig. 8. Palpation of a liver two hands.
Fig. 9. Palpation of a spleen.
Fig. 10. Palpation of a sigmoid gut.
Fig. 11. Palpation of a right kidney two hands.
Fig. 12. Palpation of a caecum two hands.
Fig. 13. Definition of the lower bound of a stomach two hands.
Fig. 14. Percussion of an abdominal cavity (according to Obraztsov).
Fig. 15. Definition of availability of free liquid in an abdominal cavity at ascites by method of percussion.

Survey stomach it is necessary to make in various provisions of the patient (taking into account his state). At survey. pay attention to its size, a form, symmetry, development of saphenas, existence and the nature of rash on skin and the available postoperative hems which character and an arrangement give the chance to judge the postponed diseases, injuries and surgical interventions. The size of a corner between costal arches is noted. The network of expanded saphenas of a front abdominal wall gives the grounds to think of difficulty of a blood-groove in large veins. At the broken outflow of blood on a portal vein venous vessels of an abdominal wall are directed from a navel in different directions — «the head of a jellyfish» (fig. 2), at disturbance of a krovoottok on the lower vena cava expanded veins of an abdominal wall go from a femoral vein (fig. 3) up.

Asymmetry. can arise at new growths in an abdominal wall or in a cavity. and at inflation of intestinal loops, at increase in abdominal organs (fig. 4). In vertical position investigated easier hernial protrusions of a front abdominal wall, discrepancy of direct muscles come to light., protrusion of the bottom. at a splanchnoptosia, ascites, big cysts of ovaries and an otvisaniye of an abdominal wall at her obesity and hypostasis.

Careful survey of a navel is necessary: at the general obesity the navel is pulled in, at a meteorism — is maleficiated, at ascites is quite often stuck out like umbilical hernia, in a navel metastasises of malignant tumors of abdominal organs often are defined.

Bruises, hemorrhages and wounds of an abdominal wall force to think of damage of bodies.

At survey. in horizontal position of the patient draw the attention of a pas participation of a front abdominal wall in breath: at local peritonitis (an acute appendicitis, a perforated ulcer etc.) the movements of its respective area are limited. At diffuse peritonitis the front abdominal wall does not take part in the respiratory movements. Degree of abdominal distention, character of the vermicular movement seen through an abdominal wall is defined. At aneurism of a ventral aorta or at the tumors located over an aorta the pulsation of a front abdominal wall sometimes is visible. At insufficiency of the three-leaved valve of heart the pulsation of a liver is sometimes noted. Survey. it is necessary to complete a laparometriya — measurement of its circle at the level of a navel for determination of its volume. Increase. can be result of the general obesity, an adiposity in a front abdominal wall, a meteorism, ascites or to arise in the presence of a big tumor or a cyst in an abdominal cavity or an abdominal wall. Laparometriya is especially valuable at repeated surveys since she reveals dynamics of changes.

Palpation — main wedge, method of a research Zh. and abdominal organs (see. Palpation ). It is necessary to begin it with a superficial approximate palpation. The research is made in lying position of the patient at the maximum relaxation of muscles of a prelum abdominale, since obviously painless sites of an abdominal wall.

At a superficial palpation define: rate of strain of an abdominal wall, morbidity., anatomic condition of an abdominal wall (adiposity, tumors, etc.), extent of increase in bodies and existence patol, educations.

The superficial palpation is carried out by the sliding movements of fingers and the brushes put on. flatwise (fig. 5). Then pass to the deep palpation which is methodically developed by V.P. Obraztsov. The deep palpation consists in immersion of fingers of a hand in depth of an abdominal cavity through an abdominal wall, pressing of body (a gut, a stomach) to a firm back abdominal wall and sliding by fingers perpendicular to an axis of body or its edge (fig. 6 — 13). At a deep palpation it is necessary to remember that many abdominal organs have a certain passive and active mobility. Disturbance of mobility of bodies can demonstrate existence patol, process; e.g., the full immovability is characteristic of retroperitoneal tumors.

Various receptions of a palpation allow to find degree and the place of morbidity in the area Zh. and to define the struck body as a source of pain. Strengthening of pain at a palpation. through an intense abdominal wall and more accurate konturirovaniye of a new growth in this case demonstrates that patol. process is localized not in an abdominal cavity, and in an abdominal wall.

At percussions (see. Percussion ) it is possible to reveal availability of liquid and free gas in an abdominal cavity, and also to gain an approximate impression about borders of separate bodies and educations in. (fig. 14 and 15). Perkutorno can define limits of absolute dullness of a liver, border of bottom edge of a liver, upper, front and lower borders of a spleen. At percussion of area of a stomach tympanic tone is slightly lower, than over intestines, percussion delimitation of a stomach is based on it. At percussion over intestines the tympanic sound of various shades is defined. At percussion in podreberye the tympanites is defined, on the area to-rogo it is possible to judge expansion ratio of a cross colon. The resistant tympanites on site of hepatic dullness happens at an arrangement of intestinal loops between a liver and a diaphragm. Obtusion in lower parts. is defined at ascites, the increased uterus, big cysts of ovaries, at the crowded bladder. Sometimes it is perkutorno possible to define borders of tumors of abdominal organs.

Free liquid in an abdominal cavity can be defined perkutorno, changing situation investigated if the quantity exceeds it 500 ml. With change of position of a body of the patient the level of dullness changes. The more liquids in an abdominal cavity, the it is easier to reveal it perkutorno. At big accumulation of liquid the phenomenon can be revealed undulations (see).

At hit of air (gas) in an abdominal cavity (pneumoperitoneum) over all front abdominal wall the high-pitched, uniform tympanic percussion sound decides on lack of hepatic dullness. Percussion causes sharp morbidity and reduction of belly muscles in places of an inflammation, especially sharply being shown during the involvement in process of a parietal peritoneum, napr, Ortner's symptom, Vasilenko's symptom at cholecystitis.

Auscultation. The sound phenomena in. can be defined at distance, directly during the applying of an ear to. investigated and by means of a phonendoscope (see. Auscultation ).

The loud, heard at distance rumbling in. as a result of a hyperperistalsis can be at almost healthy, but easily excitable people. At healthy people at auscultation. the various peristaltic noise connected with advance of a chyme on are usually listened went. - kish. to a path. At a mechanical obstacle in various levels went. - kish. a path the strengthened intestinal noise are listened — the rumbling and transfusion which are followed by pain sometimes is defined noise of «the falling drop». At a coloenteritis the hyperperistalsis is followed by the sounds similar to transfusion of liquid, gurgle, a sound of the bursting bubbles. So, e.g., the capotement defined on an empty stomach in epigastric area at slight concussion of an abdominal wall demonstrates the complicated evacuation of contents of a stomach.

Total absence of any noise in. at auscultation can be a symptom of peritonitis or paralytic intestinal impassability.

At fibrinous peritonitis the respiratory movements can be followed by a friction murmur of a peritoneum: in right hypochondrium — at an empyema of a gall bladder (F. G. Yanovsky), at a perihepatitis; in epigastriß area — at bilious or tubercular peritonitis, phlegmon of a stomach; in left hypochondrium — at an episplenitis. The friction murmur of a peritoneum can be defined occasionally in places of localization of cancer tumors or their metastasises.

Arterial noise in. can be listened at aortic aneurysms and large arteries of an abdominal cavity, at traumatic arteriovenous aneurisms, in vessels of a uterus at pregnancy.

X-ray inspection at diseases and damages of bodies. is a valuable auxiliary method. Features of its techniques and the received results at diseases are given in articles devoted to bodies. (e.g., Stomach , Gall bladder , Intestines , Liver etc.) and to individual diseases (e.g., Gastritis , Ventroptosis , Hepatitis , Colitis , Cholecystitis etc.). Carrying out rentgenol, researches at damages. it is shown in the cases difficult for diagnosis, at the erased symptomatology. If the condition of the patient allows, the bucketed .nablyudeniye in several hours is shown repeated rentgenol.

At roentgenoscopy of an abdominal cavity during the first hours after an injury restriction of respiratory movements of a diaphragm is almost always observed. Further in the presence of an internal injury symptoms of paresis of intestines owing to development come to light rentgenol, peritonitis (see) — the intestinal loops inflated by gas with fluid levels in them.

One of tasks rentgenol, researches at an injury of bodies. definition of availability of liquid and gas in an abdominal cavity is. At damages of the hollow bodies containing gas (a stomach, intestines), the survey roentgenoscopy and a X-ray analysis of an abdominal cavity in vertical position of the patient gives the chance to find free gas under a diaphragm, sometimes under a liver, and at a research in horizontal position on one side (lateroskopiya) — under a lobby or a side abdominal wall. Small amounts of liquid (to 500 ml) in an abdominal cavity radiological do not come to light. Large amounts of liquid on survey roentgenograms of an abdominal cavity sometimes decide in the form of wide strips of blackouts on scalloped contours, and also in the form of triangular or polygonal shadows between intestinal loops; contours of lumbar muscles disappear on both sides, blackout in lumbar area comes to light, the diaphragm costs highly. Additional data can give aim roentgenograms. At the intraperitoneal bleeding which developed as a result of an injury of a spleen on the survey roentgenogram of an abdominal cavity contours of a shadow of a spleen are erased, on its place homogeneous blackout comes to light. At increase of bleeding from a spleen this shadow extends up and to the right, raising a diaphragm and pushing aside the arch of a stomach and the left bend of a colon from top to bottom and medially, and below extends on the left half of an abdominal cavity.

At peritoneografiya (see) using polyposition research (see) perhaps identification of free liquid in an abdominal cavity, definition of location and ways of distribution of its small volumes (to 500 ml) which are usually not found on survey roentgenograms. Diagnostic pneumoperitoneum (see) with introduction of 200 — 300 ml of gas considerably facilitates identification of free liquid in an abdominal cavity, at the same time the border between liquid and gas in the form of horizontal level accurately is defined.

In diagnostically hard and doubtful cases carrying out an angiographic research of bodies is reasonable., a cut gives the chance before operation to specify the place of bleeding.

At ruptures of a diaphragm and moving of abdominal organs to a chest cavity the dome of a diaphragm radiological does not come to light.

To establish localization and the amount of damage of a diaphragm, distribution and the number of the bodies which moved to a chest cavity., apply a contrast research with barium which is entered through a mouth or through a rectum.

At suspicion on injury of a kidney do urography (see). Flowed a contrast agent points to damage of a parenchyma of a kidney. More informative research is the renal angiography.

Apply to confirmation of the diagnosis of a rupture of the bladder tsistografiya (see). Accumulation of a contrast agent in paravesical cellulose is a sign of an extra peritoneal gap, in an abdominal cavity — an intraperitoneal rupture of the bladder.

Special methods of a research

the Special methods of a research based on use of tools, devices and devices give the chance to obtain additional data on a condition of abdominal organs. The puncture of a back vault of the vagina or the hanging wall of a rectum, the puncture of subphrenic space or ileal areas which is carried out according to strict indications allow to judge character of the liquid which accumulated in an abdominal cavity (blood at an extrauterine pregnancy, pus at abscess of a duglasov of space or subphrenic abscess, etc.).

Laparocentesis (see) and use of the rummaging catheter give the chance to receive contents of an abdominal cavity from various departments it, to judge character patol, process and to carry out dynamic observation, especially at suspicion of intraperitoneal bleeding.

At fibrovolokonny endoscopies (see), peritoneoskopiya (see) it is possible to examine some departments and abdominal organs, and also cavities of bodies went. - kish. a path and to receive material for a biopsy.

Use fiziol, methods of a research of bodies. allows to obtain objective data on their functional state. Methods of assessment of motive activity of bodies concern to them went. - kish. a path (registration of pressure in a gleam went. - kish. a path and its motor activity by means of special radiopills, open catheters and rubber bulbs) — endoradio sounding (see), endo-radio telemetry, method of open catheters, ballonografiya; registration of biopotentials (see. Bioelectric potential ) by means of the intracavitary and superficial electrodes placed in various departments went. - kish. a path — elektrogastrografiya (see), elektroentero-and an elektrokolonografiya and on a body surface; an elektrogastromiografiya at intracavitary and intraparietal assignment; registration of noise of intestines — a phonography; studying of movement of walls of the studied body — methods of a tenzometriya, a magnetometry, an induktometriya.

A wide spread occurance at bleedings of various genesis from bodies. got scoping of the circulating blood, the specific weight of blood, indicators of erythrocytes, a hematocrit, and since the beginning of the 70th of 20 century for establishment of a bleeding point — a tracer technique (see. Gastrointestinal bleeding ). Also researches of secretory function of bodies belong to physiological methods went. - kish. a path and studying of processes of digestion — sounding of a stomach, duodenum, a method of an intragastralny rn-metriya, studying of pH of the environment by means of radiopills, methods of studying of secretion by means of stylets, methods of a research of intracavitary and pristenochny digestion, and also a research of blood circulation — a reovazografiya of a liver, a reografiya of intestines, studying of intracavitary temperature by means of radiopills.

Bacterial, researches at various diseases are also among special methods serol, and, and also definition of enzymes, enzymes in contents of bodies. and separated intestinal fistulas. The detailed description of special methods — see in articles on separate bodies of a stomach (methods of a research), and also in the description of researches of secrets and ekskret (e.g., Gastric juice , Urine etc.).

Features of a research of a stomach at children

At inspection. at children use the traditional methods of a research applied at adults (survey, a palpation, percussion, auscultation). However inspection. at children's age has a number of the details caused by age features of mentality, motive concern and excitement of the child, especially the first years of life. An important role is played by ability to find contact with the child. As the painful symptom at children is quite often connected with a delay of a chair, it is reasonable (if there are no contraindications) to inspect at them. before and after a cleansing enema.

The technique of a palpation of a front abdominal wall is important. Receptions of a palpation shall be the simplest and sparing. To feel. the child it is necessary slowly, the quiet, gentle movements of a warm hand, in the beginning slightly concerning an abdominal wall, then gradually increasing pressure. The palpation is begun with lower parts., gradually passing to podreberye. It must be kept in mind that the liver at children usually soft and its edge can easily escape at a palpation.

The sparing palpation allows to reveal localization of the greatest morbidity and existence of tension of an abdominal wall in case of acute inflammatory process in an abdominal cavity.

It is not necessary to ask the child on pain. It is necessary to watch expression of his face and reaction to a palpation, trying to distract attention of the child at this time.

If the child cries, it is necessary to wait patiently the moment of a breath and relaxation of an abdominal wall.

For differential diagnosis of a number of diseases of an abdominal cavity (invagination, a coprostasis, an acute appendicitis, pathology of genitalias at girls etc.) great practical value has manual rectal research (see).

Percussion. the child shall be easier and rather silent.

Among the receptions facilitating inspection. at children, survey and a palpation are widely applied during natural and medication sleep. Medication sleep simply, is effectively and safely reached by introduction of per rectum (after a cleansing enema) Chlorali hydras which is warmed up to the body temperature of 3% of solution. A dosage depending on age following: till 1 year — 10 — 15 ml, from 1 to 2 years — 15 — 20 ml, from 2 to 3 years — 20 — 25 ml. In 15 — 20 min. after administration of Chlorali hydras there comes the dream, and it is possible to start survey of the patient. In some cases it is necessary to resort to a research Zh. under anesthetic.

PATHOLOGY

Various funkts., inflammatory, parasitic diseases, and also tumors of bodies. are presented as in articles devoted to bodies (e.g., the Duodenum, the Stomach, the Spleen, etc.), and in articles in separate nosological forms (e.g., Appendicitis , Pancreatitis , Enteritis, coloenteritis etc.).

Damages

Damages. in peace time arise at the road accidents, during the falling from height on construction works, during the handling works, at blows in Zh. K to fighting damages more often. gunshot wounds belong, wounds cold weapon, and also the closed damages resulting from influence of a shockwave at explosion of air bombs and artillery shells, in particular at influence of a shockwave of nuclear explosions are more rare.

Damages. in peace time make 0,5 — 1% of injuries of all localizations, of them closed — 54,2-62%.

In the Great Patriotic War (1941 — 1945) wounded with damages., by data A. A. Bocharova, 2 — 5% of total number of wounded made.

In the so-called local wars which were taking place after World War II, as a result of improvement of firearms percent wounded in. considerably increased, also the number of multiple wounds of this area of a body increased. During the war in Korea wounded in. made 11%, and in Vietnam — 6,8 — 9,8% of total number of wounded. If to consider that in the conditions of use of thermonuclear weapon in view of features of its striking action the share of the severe closed injuries will increase, then it is possible to believe that not only absolute quantity of fighting injuries., but also them ud. weight in modern war can exceed the above-stated figures in total number of struck.

Fighting damages. are characterized by a number of features: the weight of wound caused by the injury of abdominal organs, peritonitis developing at once, internal bleeding, and also shock. From here dependence of result of treatment of damages. from terms of operational treatment, complexity of operations at wounded in. and need of hospitalization of victims where them operated, for the term of not less than 7 — 10 days.

Open damages. most often arise from action of firearms. During the Great Patriotic War among gunshot wounds. prevailed fragmental (61,6%) over bullet (38,4%) and getting (79,9%) over not getting (20,1%). The heaviest — the getting through missile wounds making 12,5% of total number of missile wounds. Among bullet wounds. heavier were blind people, their frequency — 14,2%. In Vietnam bullet wounds (71,8%) prevailed that was connected with the nature of fighting.

At the getting wounds. only in 50,6% the abdominal wall was area of localization of an inlet wound opening, and in 49,4% inlet opening could be located in other areas of a body. Besides, St. 30% of the getting wounds. it was combined with heavy injuries of a skull, breast, extremities that also complicated timely recognition of injury of abdominal organs. In the Great Patriotic War at injuries. hollow bodies (83,8%), and first of all intestines were most often damaged. The isolated damages of parenchymatous bodies are rare (7,2%), more often they were combined with wounds of hollow bodies (25,0%). The isolated wounds of a pancreas at the wounded who came to DMP and HPPG of the 1st line were extremely rare since at its wound large arterial vessels were damaged and most of victims perished in the battlefield. Wounds of kidneys and ureters were more often combined with damages of other bodies., with injuries of a breast and backbone. Differ in special weight thoracoabdominal damages (see). At not getting wounds. under the influence of force of side blow of a hurting shell bodies of a cavity of a stomach were sometimes damaged as extra peritoneal, so. In the latter case there were symptoms characteristic of the getting wounds.

The closed damages. in last war met seldom.

Depending on force of a shockwave hollow bodies, from them preferential small bowel were more often damaged. From parenchymatous bodies the liver and a spleen were equally often injured.

Classification. Features of the closed and open damages. were the basis for their classification.

Classification of damages is for practical purposes most convenient., offered by A. A. Bocharov.

Injuries of a stomach

The closed damages:

1. Without internal injury.

2. With an internal injury.

Open damages (wounds) — bullet, fragmental, cold weapon:

1. Not getting — through, blind, tangent: a) with damage only of an abdominal wall; b) with an internal injury (under the influence of force of side blow).

2. Getting — through, blind, tangent: a) without internal injury; b) with damage of hollow bodies; c) with damage of parenchymatous bodies; d) with the combined damage of hollow and parenchymatous bodies; e) with injury of kidneys and ureters; e) with injury of a backbone; g) thoracoabdominal wounds.

The closed damages are characterized by lack of injury of skin, however at the same time grazes, hypodermic hemorrhages and hematomas of an abdominal wall can be observed. To the closed damages. without internal injury bruises and gaps belong abdominal wall (see).

At this type of an injury damages of parenchymatous bodies, ruptures of hollow bodies or the combined damages of that and others are observed. Weight of damages at the closed injury. with an internal injury causes the big frequency of shock (on average 61%) and a high lethality (60,2%).

Victims usually complain of the severe pains in a stomach which arose at once after an injury tachycardia is noted (usually pulse more often 100 ud. / min.). The wedge, a picture depends on the nature of injuries of abdominal organs; at damage of parenchymatous bodies symptoms of massive bleeding prevail: pallor of integuments and mucous membranes, the progressing falling of the ABP, increase of pulse, shortening of a percussion sound in sloping places., tension of an abdominal wall, emergence of a symptom of Shchetkin — Blyumberg (see. Shchetkina — Blyumberg a symptom ), frenikus-symptom (see), overhang of a front wall of a rectum. At considerable bleeding in an abdominal cavity symptoms of irritation of a peritoneum can be expressed poorly. At the closed injury. subcapsular ruptures of a liver and spleen are possible; then bleeding in an abdominal cavity can begin through considerable time after an injury as a result of disturbance of an integrity of the connective tissue capsule of body the hematoma formed under it. At damage of hollow bodies peritonitis quickly develops, signs to-rogo are abdominal pains, dry language, thirst, frequent pulse, the pointed features, chest type of breath, widespread and sharp morbidity on everything., the sharp tension of an abdominal wall (see. Peritonitis ). Degree of manifestation of symptoms of damage of bodies. depends on time which passed from the moment of an injury and from the volume of the available damages.

Considerable difficulties for diagnosis at the closed damage. represents the isolated rupture of a duodenum. Wedge, a picture is defined by existence or lack of disturbance of an integrity of a back leaf of a parietal peritoneum. At damage its contents of a gut get into a peritoneal cavity and peritonitis develops. At an integrity its wedge, a picture can be veiled in the beginning. In the subsequent retroperitoneal phlegmon develops, edges can break in a peritoneal cavity and lead to development of peritonitis (see. Duodenum ).

The wedge, a picture of injury of a pancreas depends on the place and the nature of its damage. Damages to area of a head of gland are heaviest. Symptoms at injury of her body or tail are less expressed. The main signs of injury of a pancreas are intra belly bleeding and peritonitis. Increase in amount of amylase in urine facilitates the diagnosis. Injuries of a pancreas very often are followed by shock (see. Pancreas ).

Damages of a diaphragm arise usually at a prelum. and at the combined injury of a thorax and Zh. Naiboley the left part of the tendinous center is often damaged. Through the formed defect bodies Zh. Klien move to a pleural cavity, symptoms of an injury of a diaphragm are often veiled by symptoms of injury of abdominal organs (see. Diaphragm ).

At the closed injury of kidneys there are constant pains on everything., then localized in the corresponding half., in lumbar area with irradiation to the inguinal area. A constant symptom at the same time is macro - and a microhematuria (see. Hamaturia ). At a separation of a vascular leg or a rupture of an ureter the hamaturia can be absent. Lag of a front abdominal wall in the act of breath on the struck party, a positive symptom of Shchetkin — Blyumberg, a delay of a chair and gases, a muscle tension of lumbar area pays attention. Further the rise in temperature caused by formation of a pararenal hematoma is observed, edges it can be infected over time (see. Kidneys ).

Injuries of a bladder at the closed injury. are usually combined with fractures of pubic and sciatic bones (see. Bladder ).

The diagnosis of the closed damages of bodies., first of all, the wedge, symptoms shall be based on early. The main thing is establishment of existence of an internal injury and by that definition of indications to an urgent operative measure.

With the diagnostic purpose at differentiation of shock and intra belly bleeding it is necessary to apply a laparocentesis, at Krom by means of the rummaging catheter it is possible to receive blood or intestinal contents from an abdominal cavity. The laparocentesis considerably lowered number of unreasonable diagnostic laparotomies which in itself are unsafe. By data A. N. Berkutova et al., quantity of diagnostic mistakes at the closed injury. in cases of use of a laparocentesis decreased by 13 times, and reliable results are received at 98% of victims.

Open damages are characterized by a variety a wedge, manifestations. At the isolated wounds of an abdominal wall (not getting wounds) the general condition of the victim satisfactory, there are no symptoms of irritation of a peritoneum, language wet, the pulse which is not speeded up is listened a peristaltics of intestines.

Clinic of the getting wounds. depends on whether there are damages of hollow or parenchymatous bodies or a combination of these damages. The getting wounds. without internal injury meet seldom. At wounds of intestines or stomach their contents stream in an abdominal cavity that leads to development peritonitis (see). At wound of a liver or spleen there is intra belly bleeding (see). Weight of a condition of victims with the getting wounds. is defined shock (see), intraperitoneal bleeding and quickly developing peritonitis.

At diagnosis of the getting wounds. it is necessary to consider existence of absolute and relative, early and late symptoms. To absolute symptoms of the getting wounds. loss of an epiploon, intestinal loops in a wound or emergence on a bandage of intestinal contents, bile, urine belong. Rather early symptoms are tension of a front abdominal wall, disappearance or sharp restriction of respiratory excursions., symptoms of irritation of a peritoneum. Late symptoms (swelling., the fecal vomit, dry language, etc.) testify to already developed acute peritonitis.

Treatment

Conservative therapy is possible only at some closed injuries (a bruise, a subcapsular rupture of a liver, spleen, etc.).

In the presence of internal injuries treatment can be only operational therefore all victims with damages. it is necessary to deliver urgently in a surgical hospital. Doubts about existence or absence of damage of bodies., if they did not manage to be resolved in the course of inspection, are the indication for a laparotomy.

Preoperative preparation depends on the general condition of the patient and the nature of damage. At shock of the II—III degree before operation complex antishock therapy is necessary, to-ruyu it is necessary to continue during operation and after it. Antishock actions should not be continued by all means before full removal of the victim from shock since in some cases (e.g., at intra belly bleeding) an operative measure itself is an antishock action.

Anesthesia. It is better to make a laparotomy under an endotracheal anesthesia using muscle relaxants.

The section at a laparotomy shall provide survey of all abdominal cavity. Midsection is most convenient. If necessary it can be prolonged up and down, is added with cross section to the right and to the left. It is desirable not to include a wound of an abdominal wall in a section. Before opening of an abdominal cavity it is necessary to wash the dropped-out loop of a gut, a wound. to expand, make anesthesia of a mesentery a little and to set the unimpaired loop in an abdominal cavity, and damaged — to shroud in a napkin and to leave on an abdominal wall. The dropped-out epiploon needs to be tied up and dissected away, to excise entrance and output openings on an abdominal wall, and to sew up defect in a peritoneum. It at the termination is better to perform operations before mending of an operational wound.

Operative measure at damages. it is subdivided into four stages:

1. Stop of bleeding. The blood found in an abdominal cavity should be removed with tampons or an aspirator, it is necessary to establish a bleeding point and to eliminate it. The injured liver, a spleen, vessels of a mesentery, gut can be a source of plentiful bleeding. At wounds of a liver (gaps) make excision of its impractical sites, and also edges of a wound with imposing of P-shaped seams a thick catgut. Before setting of seams the epiploon on a leg keeps within (see. Liver ), then seams are pulled together. Hardly accessible wounds of a liver (area of a dome) tampon or hem a liver in the field of a wound to a diaphragm. The injured spleen is deleted most often (see. Spleen , Splenectomy ). After an alloying of the bleeding vessels of a mesentery the issue of viability of the corresponding loop of a gut is resolved at the end of operation. Capillary bleedings stop a temporary tamponade with biol, haemo static drugs. After elimination of bleeding for recognition of nature of damages and making decision on a type of operation consecutive survey of all bodies is obligatory.

2. Audit of a peritoneal cavity is made quickly, gently, without allowing eventration of intestines. Only upon termination of audit make the decision on the necessary volume of surgical intervention. During audit block solution of novocaine reflexogenic zones and enter gauze tampons into sloping places of an abdominal cavity (subphrenic space, lateral channels, a small pelvis) for the prevention of pollution at manipulations and for an osushivaniye of an abdominal cavity. Audit is begun with a stomach. Survey of its back wall, pancreas and area of a duodenum is obligatory. Loops of small bowels are consistently taken, examined and immersed back in an abdominal cavity. Especially carefully examine mesenteric edge of a gut. Sites of a gut, suspicious on wound, check for tightness by crossclamping by fingers of its gleam above and below this place and a prelum of a gut. During audit of a wound of intestines do not sew up, and bring the damaged loop shrouded in a napkin to an abdominal wall. Subserous hematomas of a gut open for the purpose of an exception of damage of its wall. For detection of damages of retroperitoneal departments of a large intestine cut a peritoneum on its outer edge and delimit a wound in a gut a tampon. Audit is finished with survey of a rectum and bladder.

3. Actually an operative measure is made depending on the found damages. The wound of a stomach, a small bowel after very economical excision of edges is sewn up with a two-row seam in transverse direction. Wounded in. badly transfer a resection and an extirpation therefore the enterectomy is admissible only at the multiple wounds which are close located to each other, at extensive ruptures of an intestinal wall or separations of a gut from a mesentery. In the Great Patriotic War in 81,7% of cases of a wound of a small bowel sewed up. At damage of retroperitoneal department of a duodenum after its mobilization on Kokhera the wound is sewn up in transverse direction, bring a tampon and a drainage zabryushinno, through counteropening in lumbar area. At the expressed narrowing of its gleam impose a gastroenteroanastomosis. Small wounds of a large intestine sew up with a two-row seam. More extensive wounds sew up with imposing of fistula on a gut above the place of wound or remove the damaged site of a gut outside through additional abdominal section. Primary resections of a large intestine with imposing of an anastomosis, as a rule, cannot be done. At crush of a gut or its necrosis primary resection with removal of both ends on an abdominal wall through an additional section is admissible. Wounds of retroperitoneal department of a large intestine sew up and bring a drainage and a tampon through counteropening in lumbar area.

At wounds of a rectum higher than 5 cm from an anus are shown imposing of an unnatural anus (see. Anus praeternaturalis ) for the purpose of its functional switching off. Closing of an unnatural anus is made through 3 — month after an injury.

Wounds of a bladder in available places sew up and impose suprapubic fistula (see. Vesicotomy ). The extensive wounds of kidneys of getting into band system demand injury of a renal leg with disturbance of food nephrectomies (see).

After elimination of the found damages at existence or threat of peritonitis enterosty needs to impose or to intubate a small bowel a long tube through enterosty, a gastrostomy or the probe entered through a mouth to distal departments of a small bowel (see. Intubation of intestines ).

4. Toilet of an abdominal cavity and closing of an operational wound. Having raised an abdominal wall, take the tampons lying in a cavity. during all operation. If necessary carry in addition out a toilet of an abdominal cavity. Through punctures of a front abdominal wall enter 1 — 4 thin chlorvinyl tubules for injection of antibiotics, carrying out peritoneal dialysis (see). The wound of an abdominal wall is layer-by-layer sewn up. Leaving of tampons in an abdominal cavity is shown: 1) at uncertainty in a stop of bleeding; 2) at injuries of a liver, pancreas, kidney; 3) at major defects of a parietal peritoneum; 4) in the presence of the abscesses opened on the course of operation (in cases of late operation). Tampons remove not through a laparotomny wound, and through additional cuts in an abdominal wall.

Postoperative leaving and treatment are directed to hl. obr. on prevention and therapy of complications. Make drop hemotransfusion and plasmas, proteinaceous drugs, intravenous or hypodermic injections of isotonic solution of sodium chloride and 5% of solution of glucose in equal quantities, the general dose of 3 — 4 l a day for two receptions within 2 — 3 days at a smooth current. Allow to drink not earlier than in two days, and appoint food taking into account localization and the nature of damage, the general state and complications.

Complications after operations for damages of hollow bodies. most often arise before the expiration of 8 — 10 days after an injury. The most frequent early complications of the closed damages and wounds. diffuse purulent peritonitis, discrepancy of edges of a wound with eventration of intestines, pneumonia are.

To prevention and treatment of peritonitis apply introduction (through tubes) in a cavity. antibiotics in 100 ml of 0,25% of solution of novocaine not less than three times a day within 4 — 5 days in combination with sulfanamide drugs and intramuscular introduction of antibiotics. Broad application is found by long injections of large amounts of liquids through an umbilical vein for the purpose of desintoxication, peritoneal dialysis, an oxygenobarotherapy (see. Hyperbaric oxygenation ), local hypothermia, etc. The great value is attached to unloading went. - kish. a path by aspiration of contents from a stomach and intestines and to recovery of proteinaceous and electrolytic balance.

In case of the eventration which developed in the postoperative period it is necessary to set the dropped-out intestinal loops in an abdominal cavity and to put stitches through all layers of an abdominal wall.

For the prevention and treatment of pneumonia, along with use of antibiotics, the oxygenotherapy, respiratory gymnastics, vagosympathetic blockade according to Vishnevsky, sanitation of a bronchial tree is widely used.

Distinguish abscesses of an abdominal cavity from rather late complications, went. - kish. fistulas, commissural intestinal impassability.

Abscesses of an abdominal cavity (subphrenic, interintestinal and pelvic abscesses) form usually slowly and are an outcome of diffuse peritonitis. Rise in temperature, a leukocytosis, abdominal pains and availability of painful infiltrate are signs of the forming abscess. In diagnosis of a subphrenic abscess the research is of great importance rentgenol (see. Subphrenic abscess ). Desires to defecation, indicate weakening of a sphincter and ponosa accumulation of pus in a small basin. It is more difficult to diagnose interintestinal abscesses until they approach an abdominal wall. Treatment of the created abscesses only operational.

Fistulas (gastric, intestinal, bilious, pancreatic) are formed as a result of insolvency of the put stitches or as a result of the seen damages. Fistulas complicate the postoperative period and what above on the course of an intestinal path they are located with, they it is more dangerous by that since quickly lead to exhaustion. Need of intervention for these cases is often dictated by vital indications.

At acute commissural intestinal impassability originally carry out conservative treatment (a gastric lavage, enemas, perinephric novocainic blockade and so forth). In case of inefficiency of these actions make relaparotomy and division of commissures.

Stage treatment. The first and pre-medical help in the battlefield or in the center of mass defeat — imposing on a wound of a big aseptic bandage, introduction of an analgetic from an unit-dose syringe and bystry evacuation from the battlefield in regimental medical aid station (see) or directly in medical and sanitary battalion (see), and in the conditions of GO — in group of first aid (see). During the rendering the first medical aid the dropped-out interiors cannot be set, they need to be fixed a bandage to an abdominal wall.

The first medical assistance on PMP consists in correction of bandages, administration of antitetanic serum with anatoxin, analgetics, antibiotics. In the presence of shock if the situation allows, carry out antishock therapy in volume of the first medical assistance (transfusion of blood substitutes, introduction of cardiovascular means) for the purpose of training of wounded for evacuation. First of all evacuate in MSB or hospital base (see) wounded with symptoms of internal bleeding, shock, with symptoms of an internal injury. In cold season before evacuation of wounded turn in a blanket, sleeping bags and lay over hot-water bottles. To shift wounded in. at stages of evacuation from a stretcher on a stretcher up to that moment when it needs to be put on the operating table, it is strictly forbidden.

The qualified help. In MSB and OMO during the sorting wounded in. allocate:

1. Victims with symptoms of internal bleeding in an abdominal or pleural cavity (thoracoabdominal wounds), and also with symptoms of considerable bleeding at injuries of kidneys. They are immediately sent to the operating room.

2. Victims with internal injuries without the expressed signs of shock. They are also subject to operational treatment. At mass receipt when it is impossible to operate in the next few hours of all wounded in., it is admissible this group to evacuate the air transport in the nearest hospital.

3. Mi Zh. who were injured from damage, complicated by shock of the II—III degree (without symptoms of internal bleeding), send to antishock department. This category of wounded belongs to temporarily inoperable. At this group of victims efficiency of antishock therapy shall be revealed in the next 2 — 3 hours. During this term distinguish two groups from temporarily inoperable: a) wounded from whom it was succeeded to achieve recovery of the major vital signs and raising of the ABP to 80 — 90 mm of mercury.; they should be transferred to the operating room and to operate, considering that a condition of the reached balance at damages. cannot be long; b) inoperable wounded from whom it was not succeeded to achieve recovery of the broken functions of an organism and which ABP have lower than 80 mm of mercury.; they are subject to conservative therapy.

4. Needing in short-term (within 2 — 3 hours) dynamic observation when the diagnosis and indications to an operative measure remain not clear. These wounded are sent to a hospital, and in the presence of shock — to antishock department.

5. Late brought wounded in satisfactory condition at whom peritonitis tends to an otgranicheniye. They are sent to a hospital for observation and conservative treatment.

6. Agoniruyushchikh, and also wounded who have obviously incompatible with life combined or combined defeats. They are sent to a hospital for use of symptomatic means.

7. Victims with not getting wounds. (without internal injuries), and also with bruises of an abdominal wall. They are evacuated in hospital for lightly wounded or all-surgical hospital.

After operation wounded with damage of bodies. are nontransportable during 8 — 10 days. At evacuation by the air transport these terms can be reduced to 4 — 5 days. At development of complications terms of evacuation are extended before their elimination.

In the conditions of civil protection of victims with damage. evacuate in OPM where complex therapy of shock is carried out and surgeries according to vital indications (the proceeding intra belly bleeding) are performed. At mass receipt if in the course of medical sorting is established that victims with damage. it is not possible to send to operational OPM in the next few hours, they should be evacuated urgently sparing type of transport in corresponding pro-thinned out-tsu hospital base (see). The exception should be made for wounded in an agonal state and for at what the nature of damage is incompatible with continuation of life; in these cases apply the means alleviating suffering.

Specialized medical care wounded in. it is carried out in specialized surgical hospitals of GB of the front or in pro-thinned out-tsakh the GO hospital base. It consists in an aftercare of the wounded operated in MSB, OMO or OPM, identification and treatment of late complications and also in carrying out recovery operations. Concerning wounded who were not operated at the previous stages, surgical tactics generally same, as in MSB, OMO or OPM.

Injuries of a stomach at children

the Closed damages can occur at any children's age, including and at newborns at a birth trauma. This injury arises in connection with discrepancy of the sizes of a fruit and patrimonial ways, at the wrong rough carrying out revival of the newborn who was born in asphyxia. The children who were born with funic hernia can have a rupture of a hernial bag to the subsequent loss and damage of bodies of Zh. U of newborns are more often injured parenchymatous (liver), hollow bodies are more rare. Big frequency of injury of a liver is caused by its big size and existence in it in some cases patol, changes (hemangiomas, lymphangiomas). Usually in these cases there are insignificant subcapsular ruptures of a parenchyma of a liver to the subsequent bleeding in an abdominal cavity after disturbance of an integrity of the capsule. Klien, a picture of subcapsular ruptures of a liver is rather characteristic: after the birth the child is usually active, well sucks a breast, however soon becomes sluggish, apathetic, there are symptoms of internal bleeding (pallor of integuments, cold sweat, vomiting, becomes frequent pulse, the ABP falls, the amount of hemoglobin and erythrocytes decreases). At a palpation the muscle tension of a front abdominal wall and sharp morbidity is defined. At rentgenol, a research restriction of mobility of the right dome of a diaphragm is noted. At newborns at the same time parenchymatous and hollow bodies can sometimes be damaged. In such cases the clinic of peritonitis is combined with symptoms of intra belly bleeding.

Among birth trauma. hemorrhages in adrenal glands, patol which symptoms are shown already by the end of the first days after the birth of the child sometimes occur at newborns. In a wedge, a picture symptoms of injury of abdominal organs prevail in the beginning: vomiting with impurity of bile, abdominal distention, tension of a front abdominal wall. Then the condition of the child quickly worsens, pallor, slackness increases, vomiting becomes frequent. Pulse is threadlike, blood pressure falls, the expressed anemia is noted. In lumbar area the swelling of a plotnoelastichny consistence konturirutsya.

The intravenous urography reveals infraplacement of a kidney, edges it is represented increased in sizes because of a hematoma of an adrenal gland. At biochemical, a blood analysis and urine the hypoglycemia, a hyperpotassemia, increase in urea in blood, decrease in corticosteroids in blood and urine are defined.

At children of preschool and school age of injury of abdominal organs usually result from autoinjuries, bruises during the falling from height, blows in. From parenchymatous bodies their spleen (40 — 50%) is most often injured, from hollow bodies — a small bowel.

At injury of a spleen, despite a considerable loss of blood, stability of hemodynamic indicators is quite often observed.

The wedge, a picture of injury of a liver depends on size, extent and localization of a rupture of a parenchyma and the capsule. In one cases it proceeds as massive intra belly bleeding, in others — symptoms of bleeding accrue gradually.

At injuries of a stomach and intestines in a wedge, a picture symptoms of shock, development prevail to-rogo is an early and constant symptom of damage of an integrity went. - kish. a path at children and peritonitis.

An early and constant symptom of damage of a gut at children is shock.

Feature of injury of kidneys at children — discrepancy between a damage rate, sometimes insignificant, and weight a wedge, pictures, edges is often characterized by shock. Injuries of a bladder occur at children seldom.

Treatment of the closed and open damages. at children it is carried out by the same principles, as at adults. Features of surgical tactics at them show need of the maximum atravmatichnost of an operative measure, a careful stop of bleeding, the minimum volume of a resection of hollow bodies, and for the postoperative period — full compensation of blood loss and bystry normalization of disturbances of content of electrolytes and acid-base equilibrium.

See also Abdominal cavity , Abdominal wall and articles devoted to bodies. ( Duodenum , Stomach , Intestines , Liver etc.).



Bibliography:

Anatomy — Valker F. I. Morphological features of the developing organism, page 111, L., 1959; Surgical anatomy of a stomach, under the editorship of A. N. Maksimenkov, M., 1972, bibliogr.; Gouinaud C. Anatomie de l'abdomen, P., 1963.

Pathology — Bairov G. A. Urgent surgery of children, page 277, L., 1973, bibliogr.; A. A. coopers. Injuries of a stomach, M., 1967, bibliogr.; Vasilyev P. X. The combined laparoscopy, Tashkent, 1976; Vishnevsky A. A. and Schreiber M. I. Field surgery, M., 1975; 3akurdayev V. E. Diagnosis and treatment of injuries of a stomach at a multiple injury, L., 1976, bibliogr.; Zedgenidze G. A. and Linda of L. D N-braten. Urgent radiodiagnosis, L., 1957; The Multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 7, L., 1960; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 12, M., 1949; Poles V. A. and Khromov B. M. The surgical help at stages of evacuation of health service of civil protection, M., 1969, bibliogr.; The guide to an urgent surgery of abdominal organs, under the editorship of V. S. Savelyev, M., 1976; With and l and m and t and B. N. N and C y at l I to G. N. O injuries of a stomach, Voyen. - medical zhurn., No. 7, page 20, 1968; In i-e of A. u. a. Chirurgische Operationslehre, Bd 4, T. 1 — 2, Lpz., 1972 — 1975; G o r-n a 1 1 P. a. o. Intra-abdominal injuries in the battered baby syndrome, Arch. Dis. Childh., v. 47, p. 211, 1972.


G. A. Pokrovsky; A. F. Dronov (ped.), K. M. Lisitsyn (soldier.), S. S. Mikhaylov (An., embr.), N. B. Sitkovsky (it is put. hir.).

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