Works by N. Pirogov (Structure of fascial sheaths of the limb)
Soft frame.
Purpose of the lecture. To familiarize students with the current state of the issue of connective tissue structures of the human body.
lecture plan:
1. General characteristics of the soft frame. Classification of human fascia.
2. General characteristics of the distribution of fascial formations in the human body.
3. Basic patterns of distribution of fascial formations in human limbs.
4. Clinical significance of fascial sheaths; the role of domestic scientists in their study.
The history of the study of fascial sheaths of muscles, vessels and nerves begins with the work of the brilliant Russian surgeon and topographic anatomist N.I. Pirogov, who, based on a study of cuts of frozen corpses, revealed topographic-anatomical patterns of the structure of vascular fascial sheaths, summarized by him in three laws:
1. All main vessels and nerves have connective tissue sheaths.
2. On a cross section of the limb, these sheaths have the shape of a triangular prism, one of the walls of which is also the posterior wall of the fascial sheath of the muscle.
3. The apex of the vascular sheath is directly or indirectly connected to the bone.
The compaction of the muscle groups' own fascia leads to the formation aponeuroses. The aponeurosis holds the muscles in a certain position, determines lateral resistance and increases the support and strength of the muscles. P.F. Lesgaft wrote that “the aponeurosis is as independent an organ as the bone is independent, which makes up the solid and strong support of the human body, and its flexible continuation is the fascia.” Fascial formations should be considered as a soft, flexible skeleton of the human body, complementing the bone skeleton, which plays a supporting role. Therefore, it was called the soft skeleton of the human body.
A correct understanding of fascia and aponeuroses forms the basis for understanding the dynamics of the spread of hematoma during injuries, the development of deep phlegmon, as well as for justifying case novocaine anesthesia.
I. D. Kirpatovsky defines fascia as thin translucent connective tissue membranes covering some organs, muscles and vessels and forming cases for them.
Under aponeuroses This refers to denser connective tissue plates, “tendon sprains”, consisting of tendon fibers adjacent to each other, often serving as a continuation of the tendons and delimiting anatomical formations from each other, such as the palmar and plantar aponeuroses. The aponeuroses are tightly fused with the fascial plates covering them, which beyond their boundaries form a continuation of the walls of the fascial sheaths.
CLASSIFICATION OF FASCIA
Based on their structural and functional characteristics, they distinguish between superficial, deep and organ fascia.
Superficial (subcutaneous) fascia
, fasciae superficiales s. subcutaneae, lie under the skin and represent a compaction of subcutaneous tissue, surround all the muscles of this area, are connected morphologically and functionally with subcutaneous tissue and skin and together with them provide elastic support for the body. The superficial fascia forms the casing for the entire body as a whole.
Deep fascia, fasciae profundae, cover a group of synergistic muscles (i.e., performing a homogeneous function) or each individual muscle (own fascia, fascia propria). When the muscle's own fascia is damaged, the latter protrudes in this place, forming a muscle hernia.
Own fascia(organ fascia) covers and insulates an individual muscle or organ, forming a sheath.
Proper fascia, separating one muscle group from another, gives off processes deep into the intermuscular septa, septa intermuscularia, penetrating between adjacent muscle groups and attaching to bones, as a result of which each muscle group and individual muscles have their own fascial beds. For example, the own fascia of the shoulder gives off the external and internal intermuscular septa to the humerus, resulting in the formation of two muscle beds: the anterior one for the flexor muscles and the posterior one for the extensors. In this case, the internal muscular septum, splitting into two leaves, forms two walls of the vagina of the neurovascular bundle of the shoulder.
Proprietary fascia of the forearm, being a case of the first order, gives off intermuscular septa, thereby dividing the forearm into three fascial spaces: superficial, middle and deep. These fascial spaces have three corresponding cellular slits. The superficial cellular space is located under the fascia of the first layer of muscles; the middle cellular fissure extends between the flexor ulnaris and the deep flexor of the hand; distally this cellular fissure passes into the deep space described by P. I. Pirogov. The median cellular space is connected with the ulnar region and with the median cellular space of the palmar surface of the hand along the median nerve.
In the end, as V.V. Kovanov states, “ fascial formations should be considered as a flexible skeleton of the human body, significantly complementing the bone skeleton, which, as is known, plays a supporting role." Detailing this position, we can say that in functional terms fascia plays the role of flexible tissue support , especially muscles. All parts of the flexible human skeleton are built from the same histological elements - collagen and elastic fibers - and differ from each other only in their quantitative content and orientation of the fibers. In aponeuroses, connective tissue fibers have a strict direction and are grouped into 3-4 layers; in fascia there is a significantly smaller number of layers of oriented collagen fibers. If we consider the fascia layer by layer, then the superficial fascia is an appendage of the subcutaneous tissue; the saphenous veins and cutaneous nerves are located in them; The intrinsic fascia of the limbs is a strong connective tissue formation covering the muscles of the limbs.
ABDOMINAL FASCIA
There are three fascia on the abdomen: superficial, intrinsic and transverse.
Superficial fascia separates the abdominal muscles from the subcutaneous tissue in the upper sections and is weakly expressed.
Own fascia(fascia propria) forms three plates: superficial, middle and deep. Superficial plate covers the outside of the external oblique muscle of the abdomen and is most developed. In the area of the superficial ring of the inguinal canal, the connective tissue fibers of this plate form interpeduncular fibers (fibrae intercrurales). Attached to the external lip of the iliac crest and to the inguinal ligament, the superficial plate covers the spermatic cord and continues into the fascia of the muscle that lifts the testicle (fascia cremasterica). Medium and deep plates its own fascia covers the front and back of the internal oblique muscle of the abdomen, and is less pronounced.
Transversalis fascia(fascia transversalis) covers the inner surface of the transverse muscle, and below the navel it covers the posterior rectus abdominis muscle. At the level of the lower border of the abdomen, it is attached to the inguinal ligament and the inner lip of the iliac crest. The transverse fascia lines the anterior and lateral walls of the abdominal cavity from the inside, forming most of the intra-abdominal fascia (fascia endoabdominalis). Medially, at the lower segment of the white line of the abdomen, it is strengthened by longitudinally oriented bundles, which form the so-called support of the white line. This fascia, lining the inside of the abdominal wall according to the formations it covers, receives special names (fascia diaphragmatica, fascia psoatis, fascia iliaca).
Case structure of fascia.
The superficial fascia forms a kind of case for the entire human body as a whole. Their own fascia forms cases for individual muscles and organs. The case principle of the structure of fascial containers is characteristic of the fascia of all parts of the body (torso, head and limbs) and the organs of the abdominal, thoracic and pelvic cavities; it was studied in particular detail in relation to the limbs by N. I. Pirogov.
Each section of the limb has several sheaths, or fascial bags, located around one bone (on the shoulder and thigh) or two (on the forearm and lower leg). For example, in the proximal part of the forearm, 7-8 fascial sheaths can be distinguished, and in the distal part - 14.
Distinguish main case (sheath of the first order), formed by fascia running around the entire limb, and second order cases , containing various muscles, blood vessels and nerves. N.I. Pirogov’s theory about the sheath structure of the fascia of the extremities is important for understanding the spread of purulent leaks, blood during hemorrhage, as well as for local (sheath) anesthesia.
In addition to the case structure of the fascia, recently the idea of fascial nodes , which perform a supporting and restrictive role. The supporting role is expressed in the connection of the fascial nodes with the bone or periosteum, due to which the fascia contributes to muscle traction. Fascial nodes strengthen the sheaths of blood vessels and nerves, glands, etc., promoting blood and lymph flow.
The restrictive role is manifested in the fact that fascial nodes delimit some fascial sheaths from others and delay the movement of pus, which spreads unhindered when the fascial nodes are destroyed.
Fascial nodes are distinguished:
1) aponeurotic (lumbar);
2) fascial-cellular;
3) mixed.
By surrounding the muscles and separating them from each other, fascia promotes their isolated contraction. In this way, the fascia both separates and connects the muscles. According to the strength of the muscle, the fascia covering it thickens. Above the neurovascular bundles, the fascia thickens, forming tendon arches.
Deep fascia, which forms the covering of organs, in particular the own fascia of muscles, is fixed to the skeleton intermuscular septa or fascial nodes. With the participation of these fasciae, the sheaths of the neurovascular bundles are built. These formations, as if continuing the skeleton, serve as a support for organs, muscles, blood vessels, nerves and are an intermediate link between fiber and aponeuroses, so they can be considered as the soft skeleton of the human body.
Have the same meaning bursae , bursae synoviales, located in various places under the muscles and tendons, mainly near their attachment. Some of them, as indicated in arthrology, connect to the articular cavity. In those places where the muscle tendon changes its direction, a so-called block, trochlea, through which the tendon is thrown, like a belt over a pulley. Distinguish bone blocks, when the tendon is thrown over the bones, and the surface of the bone is lined with cartilage, and a synovial bursa is located between the bone and tendon, and fibrous blocks formed by fascial ligaments.
The auxiliary apparatus of muscles also includes sesamoid bones ossa sesamoidea. They are formed in the thickness of the tendons at the points of their attachment to the bone, where it is necessary to increase the leverage of muscle force and thereby increase the moment of its rotation.
The practical significance of these laws:
The presence of a vascular fascial sheath should be taken into account during the operation of exposing the vessels during their projection. When ligating a vessel, a ligature cannot be applied until its fascial sheath is opened.
The presence of an adjacent wall between the muscular and vascular fascial sheaths should be taken into account when performing extra-projection access to the vessels of the limb. When a vessel is injured, the edges of its fascial sheath, turning inward, can help spontaneously stop bleeding.
Test questions for the lecture:
1. General characteristics of the soft frame.
2. Classification of abdominal fascia.
3. General characteristics of the distribution of fascial formations in the human body.
4. Basic patterns of distribution of fascial formations in human limbs.
Brought up in the best traditions of the Russian medical school, Nikolai Ivanovich Pirogov (1810-1881) launched a broad creative scientific activity that lasted over 45 years. The works of N. I. Pirogov in the field of topographic and surgical anatomy indicate that he is the founder of this science.
N. I. Pirogov (1810-1881).
The outstanding Soviet surgeon N. N. Burdenko wrote that N. I. Pirogov “created new research methods in the study of anatomy, new methods in clinical medicine, and also created military field surgery. In these works, in the philosophical and scientific part, he gave a method, established the dominance of the method and showed an example of the use of this method. In this Pirogov found his glory" (N. N. Burdenko, On the historical characteristics of the academic activity of N. I. Pirogov (1836-1854), No. 2, p. 8, 1937).
In scientific research, N.I. Pirogov attached great importance to the method. He said: “In special studies, method and direction are the main thing” (N.I. Pirogov, Regarding the studies of Russian scientists abroad, newspaper “Golos”, No. 281, 1863).
Even at the dawn of his scientific activity, N.I. Pirogov, developing a dissertation topic on ligation of the abdominal aorta, showed that when using the method of one-stage ligation of the abdominal aorta, most of the animals die, while gradual compression of the abdominal aorta usually preserves the life of animals and prevents the development those severe complications that are caused by one-stage dressing. N. I. Pirogov also applied a number of original and highly fruitful research methods in the study of topographic anatomy.
Topographic anatomy existed before Pirogov. For example, manuals on topographic (surgical) anatomy by French surgeons Velpeau, Blandin, Malguigne and others are known (similar courses published before the appearance of Pirogov’s works in other countries were essentially copies of the French ones). All of these guides are surprisingly similar to each other, both in name and content. And if at one time they played a certain role as reference books in which information useful for surgeons was collected, grouped by areas of the human body, then the scientific value of these manuals was relatively small for a number of reasons.
Firstly, the materials presented in the manuals were largely devoid of scientific accuracy, since precise methods of topographic-anatomical research did not yet exist; This led to the fact that gross errors were made in the manuals, not to mention the fact that they lacked a truly scientific direction that would meet the needs of practice. Secondly, in a number of cases, the most important requirement of a truly topographic study of areas, important for the purposes of surgical practice, was not fulfilled. In the manufacture of preparations aimed at showing the most important topographic-anatomical relationships of various organs, the cellular and fascial elements holding the neurovascular bundles were removed or landmarks were ignored.
In “Surgical Anatomy of Arterial Trunks and” N.I. Pirogov wrote: “...What’s worse is that the authors do not explain the artificiality... of the position of the parts and thus give students inaccurate, false concepts about the topography of a particular area. Take a look, for example, at the 2nd, 3rd and 4th tables of Velpeau's anatomy and you will see that it is extremely difficult to judge from it the true position and distance of nerves, veins and muscles from the carotid, subclavian and axillary arteries... No one of... the authors does not give us a complete surgical anatomy of the arteries: neither Velpeau nor Blunden have drawings of the brachial and femoral arteries... None of the authors gives us drawings from preparations of the fascia that cover the brachial and femoral arteries and which should be carefully open and cut when ligating the artery. The atlases of Tiedemann, Scarpa and Manek have nothing to do with the surgical anatomy of the arteries” (N.I. Pirogov, Surgical anatomy of the arterial trunks and faculties, St. Petersburg, p. VI, 1881).
The works of N. I. Pirogov made a complete revolution in ideas about how topographic anatomy should be studied, and brought him world fame. The Academy of Sciences in St. Petersburg awarded Pirogov the Demidov Prize for each of his three outstanding works related to the field of topographic anatomy: 1) “Anatomia chirurgica truncorum arterialium atque fasciarum fibrosarum” (1837) (“Surgical anatomy of arterial trunks and fascia”); 2) “A complete course of applied anatomy of the human body with drawings. Descriptive-physiological and surgical anatomy" (only a few issues dedicated to the limbs were published, 1843-1845); 3) “Anatome topographica sectionibus per corpus humanum congelatum triplici directione ductis illustrata” (“Topographic anatomy, illustrated by sections drawn through the frozen human body in three directions”) (1852-1859).
Already in the first of these works, N. I. Pirogov illuminated the tasks of surgical anatomy in a completely new way; in it, for the first time, a new direction in surgery - anatomical - found an unusually complete expression. N.I. Pirogov established the most important laws of relationships and fascia for surgical practice, which form the basis of topographic anatomy as a science (see Chapter 3).
"Anatome topographica" is a large atlas containing 970 drawings that depict cuts of various areas of the frozen human body. The atlas is accompanied by explanations in Latin, amounting to 796 pages of neat text. The creation of the atlas of cuts, which completed the gigantic work of N.I. Pirogov, was a triumph of Russian medical science: before him, nothing had been created equal to this atlas in idea and its implementation. The relationships of organs are presented in this atlas with such exhaustive completeness and clarity that Pirogov’s data will always serve as a starting point for research in this area.
None of the topographic-anatomical research methods that existed before N.I. Pirogov can be considered truly scientific, because they did not comply with the basic requirement for conducting such research: preserving organs in their natural, undisturbed position. Only the method of cutting a frozen corpse gives the most accurate idea of the actual relationship of organs (it goes without saying that the modern x-ray method of studying topographic-anatomical relationships is the greatest achievement of medical science).
The greatest merit of N. I. Pirogov is that both in “Applied Anatomy” and in “Topographic Anatomy” he gave his research an anatomical and physiological direction. At first glance, it may seem that by studying the topography of organs on cuts, we cannot understand anything other than the static position of the organs. However, such a view is clearly misleading. Pirogov’s brilliant idea is that he used his cutting method to study not only morphological statics, but also the function of organs (for example, joints), as well as differences in their topography associated with changes in the position of certain parts of the body and the condition of neighboring organs (see Chapter 2).
N.I. Pirogov also used the cutting method to develop the question of the most appropriate access to various organs and rational surgical techniques. Thus, having proposed a new method of exposing the common and external iliac arteries, Pirogov made a series of cuts in directions corresponding to the skin incisions during these operations. Pirogov's cuts clearly show the significant advantages of both of his methods compared to the methods of Cooper, Abernethy and others.
It is important to note that when developing his methods for exposing the iliac arteries, Pirogov tested them several hundred times on corpses, and then ligated these vessels 14 times on patients.
The second original way of studying the topography of internal organs, proposed and implemented by N. I. Pirogov, was called anatomical sculpture by him. This method is not inferior in its accuracy to the study of topography on cuts of frozen corpses (for details, see Chapter 2).
Thus, the enormous merits of N. I. Pirogov in the field of topographic anatomy are that he:
1) created the doctrine of the relationship between blood vessels and fascia;
2) laid the foundations of topographic anatomy as a science, for the first time widely using the method of cutting frozen corpses, anatomical sculpture and experiment on a corpse; 3) showed the importance of topographic-anatomical studies for studying organ function;
4) established changes in the topography of a number of areas associated with different functional states of organs or the development of pathological processes in them;
5) laid the foundation for the doctrine of individual variability in the shape and position of organs;
6) for the first time established the relationships between various parts of the central nervous system and clarified the topography of peripheral nerves and connections between them, drawing attention to the significance of these data for practice; for the first time presented a topographic-anatomical description of the hand and fingers, cellular spaces of the limbs, face, neck, outlined the detailed topography of the joints, nasal and oral cavity, chest and abdominal cavity, fascia and pelvic organs;
7) used data from topographic and anatomical studies to explain the mechanism of occurrence of a number of pathological conditions and to develop rational surgical approaches and techniques.
From all that has been said, it undoubtedly follows that N.I. Pirogov is the founder of topographic anatomy as a science. His works had and continue to have a huge influence on the development of all topographic anatomy.
However, it was not only the cadaver experiment that Pirogov widely used that contributed to the development of surgical knowledge. N.I. Pirogov also carried out experiments on animals on a large scale, and Pirogov’s experimental surgical activities constitute a significant part of his scientific creativity. Already in Pirogov’s dissertation on ligation of the abdominal aorta, his enormous talent was revealed both in setting up experiments and in interpreting their results. N.I. Pirogov has priority in a number of issues of circulatory pathology. His experiments with cutting the Achilles and the results of his study of the healing process of tendon wounds have not lost scientific value to this day. Thus, Pirogov’s installations were confirmed in modern research by the outstanding Soviet biologist O. B. Lepeshinskaya. Pirogov's experiments on studying the action of ethereal vapors are considered classic.
N.I. Pirogov, as it were, foresaw what our brilliant compatriot expressed and so brilliantly implemented in his activity, unprecedented in scope and results, to whom the wonderful words belong: “Only by going through the fire of experiment, all medicine will become what it should be , i.e. conscious, and therefore always and completely purposefully acting.”
B -11 ) Founder of the top. Anatomy Russian scientist I. I. Pirogov , the works of his works revolutionized anatomy. He established the laws of relationships between blood vessels and fascia, created an extensive atlas of cuts, and proposed methods for transverse, sagittal, and frontal cuts of frozen corpses. He studied anatomically and functionally: that is, he made cuts in various end positions. After freezing, I filled the stomach, MP with water, and intestines with air. He proposed skin-plastic amputations of the lower leg. From this moment on, a department was created in Moscow. Univ. – Bobrov, Dyukonov, Saratov – Spasokukotsky, Kazan. Shevkunenko is the founder of a school for the study of individual variability in the shape and position of organs. Investigated differences in the insertion of arteries and veins, nerve trunks. Differences in shape and position associated with age. Opera technology will intervene. Surgery is a mechanical effect on the patient’s tissues and organs, performed by a doctor for the purpose of treatment or Ds.
2) Frontal-parietal-occipital region . The boundaries in front are the upper edge of the orbit, and in the back are the external occipital protuberance and the top. nuchal line, side – top. temporal line of the parietal bone. Layers: skin, subcutaneous tissue, vessels pass over the aponeurosis, their walls are tightly connected to fibrous bridges. Lymph. vessels flow into the region. nodes and arr. 3 gr.:
1 – superficial parotid. 2 – behind the ear. 3 – occipital. Lymph on the cranial vault. there are no nodes. The muscular aponeurotic layer, consisting of the frontal muscle in front, the occipital muscle in the back, a layer of loose fiber separates the muscle from the periosteum. The periosteum is connected to the skull bone also through loose fiber. The bones of the skull consist of outer and inner plates between which there is a spongy substance. Due to the presence of connections between the extracranial and intracranial venous systems, transmission of infection from the integument of the skull to the brain is possible. membranes with the subsequent development of meningitis and other diseases.
3) Bladder ( cystotomy and resection technique): MP nah-xia behind the pubic fusion. They are distinguished: apex, body, bottom, neck. Int. the submucosal layer forms folds. In the region the bottom has a triangular-shaped area of mucus where there is no submucosal layer. It is firmly fused with the muscle layer. Involuntary sphincter at the beginning of the urethra, voluntary sphincter at the membranous opening of the urethra. The symphysis is adjacent to the front, and the body of the prostate and sperm is adjacent to the bottom. vesicles, vas deferens. From above and from the sides - loops of the small intestine, sigmoid colon. Posteriorly: in women – the body and fundus of the uterus, in men – the rectum. Kr\supply – from internal. iliac arteries. Veins form plexuses and drain into the interior. subliminal vein. Lymph. vessels - in the anterior and internal iliac nodes. Innervation - hypogastric plexus. Cystotomy- incision along the midline from the symphysis to the navel. Skin and fat are cut. cellulose, aponeurosis, linea alba. The muscles are moved apart, the transverse fascia and tissue are bluntly pushed aside, and the tissues are exposed. Art. bubble, cut longitudinally. The liquid is released, a special 1.5 cm catheter is inserted into the opened bladder, obliquely cut and the end is rounded, the cut wall above and below the tube is tightly sutured with interrupted catgut sutures, the drainage is brought out at the upper corner of the wound, the wound is sutured in layers. Resection- the bladder is isolated from the apex, peeled off from the peritoneum and the ligament of the urinary duct is crossed, the pelvic part of the ureter is isolated and it is crossed 3 cm from the point of entry into the bladder. The bladder is replaced with a segment of the intestine, or the ureter is brought to the anterior abdominal wall.
B-3
1.Hir. oper.- called a mechanical effect on the patient’s tissues and organs, performed by a doctor for the purpose of treatment, diagnosis or restoration of the functions of an organism and carried out mainly through incisions and various methods of connecting tissues. In most surgical operations, it is customary to distinguish two main elements - operational access and operational reception.
^ Online access called the part of the operation that provides the surgeon with exposure of the organ on which it is planned to perform one or another surgical intervention.
^ Operational method They call the main part of the surgical intervention on the affected organ, the chosen method of eliminating the pathological focus, the features of the technique of this operation.
^ The operation consists of successive elements:
Preparing the patient for surgery, pain relief and performing the surgical intervention itself.
Surgical intervention includes: 1) tissue incision to expose the affected organ; 2) performing an operation on the organ itself; 3) connection of tissues damaged during surgery.
According to the nature and purposes of operative surgery. interventions can be divided into 2 groups : radical and palliative.
radical called surgical interventions, in which they strive to completely eliminate the pathological focus.
palliative called surgical interventions, which are aimed at alleviating the patient’s condition (if it is impossible to remove the affected organ) and eliminating life-threatening symptoms.
Operations can be single-stage, two-stage or multi-stage.
Most operations are carried out in one stage, during which all necessary measures are carried out to eliminate the cause of the disease; these are one-stage operations. Two-moment oper. performed in cases where the patient’s health condition or the risk of complications does not allow the surgical intervention to be completed in one stage. If the surgeon Since interventions are performed several times for the same disease, such operations are called repeated.
^ By urgency executions are distinguished emergency, urgent and planned operations.
emergency require immediate implementation. For example, stopping bleeding, opening the windpipe (tracheotomy), Urgent are considered, the implementation of which can be postponed for a short period of time necessary to clarify the diagnosis and prepare the patient for surgery. Planned called hir. interventions performed after a systematic examination of the patient and preparation for surgery.
All operations according to their target orientation are divided into 2 groups: therapeutic and diagnostic.
Therapeutic aims are to remove the source of the disease or restore impaired organ function.
K diagnostician. include biopsy, vasography, and in some cases, exploratory laparotomy, thoracotomy, and other interventions aimed at clarifying the diagnosis.
^ 2. AXILLAR REGION (REGIO AXILLARIS) The area contains soft tissue located near the shoulder joint and chest. Borders: front- lower edge of the pectoralis major muscle; back- the lower edge of the latissimus dorsi and teres major muscles; internal line(conditional), connecting the edges of the indicated muscles on the chest; external- a line connecting the same edges on the inner surface of the shoulder. With the limb abducted, the area looks like a hole (or depression) fossa axillaris, which, after removing the skin, fascia, fiber, vessels and nerves, turns into a cavity (cavum, s. spatium axilare).
LAYERS. Leather contains a large number of apocrine and sebaceous glands.
^ Superficial Fascia Proper Fascia (fascia axillaris)
After removing the own fascia, the muscles that limit the axillary cavity are exposed. The latter has the shape of a truncated quadrangular pyramid with the base facing downwards. Walls axillary cavity front- mm. pectoralis major and minor; posterior - mm.subscapularis,1atissimus dorsi and teres major; internal- lateral part of the chest (up to the fourth rib inclusive), covered with m. serratus anterior; external- the medial surface of the humerus with the t. coracobrachialis covering it and the short head of the t. biceps.
In the posterior wall of the armpit, two openings are formed between the muscles through which blood vessels and nerves pass.
Medial-trilateral(foramen trilaterum). It is limited: from above - mm. subscapularis and teres minor, below m.teres major, laterally long head m. triceps. The vasa circumflexa scapulae pass through it.
Lateral-quadrilateral(foramen quadrilaterum). It is limited: from above - mm.
Subscapularis and teres minor, below m. teres major, medially long head m. triceps, lateral - surgical neck of the humerus. n pass through it. axillaris and vasa circumf1exa humeri posteriora.
^ The contents of the armpit are: 1) loose fatty tissue; 2) lymph nodes; 3) a. axillaris with its branches; 4) v. axil1aris with its tributaries; 5) plexus brachialis with nerves extending from it; 6) cutaneous branches of the II and (often) PI intercostal nerve, involved in the formation of n. intercostobrachia1is, which connects with n. cutaneus brachii media1is.
^ Fiber in the axillary region is concentrated:
1) in the walls and between the walls of the axillary cavity;
2) under the axillary fascia, in the subfascial space;
3) in the sheath of the neurovascular bundle.
lymph nodes The axillary region consists of five interconnected groups.
1. Nodes lying at the lateral wall 2. Nodes lying on the medial wall 3. Nodes lying on the posterior wall of the cavity 4. Nodes located in the center of the fat accumulation of the axillary cavity
5. Nodes lying in trigonum c1avipectora1e, near v. achillaris, - apical. The lymph nodes of the axillary region are often the source of ulcers that form here, when the infection in injuries and diseases of the hand and fingers is transmitted through the lymphatic tract. This leads to the formation of adenophlegmon.
^ 3. SMALL INTESTINEJejunum (Gejunum) And ileum (ileum) occupy most of the lower floor of the abdominal cavity. The jejunal loops lie primarily to the left of the midline, and the ileal loops lie primarily to the right of the midline. Part of the loops of the small intestine is placed in the pelvis.
The small intestine is separated from the anterior abdominal wall by the greater omentum.
Behind, lie, organs that are located on the back. abdominal wall and separated from the small intestine by the parietal peritoneum: kidneys (partially), lower part of the duodenum, large blood vessels (inferior vena cava, abdominal aorta and their branches). From above, the small intestine is in contact with the transverse colon and its mesentery. From below, the intestinal loops, descending into the pelvic cavity, lie in men with the large intestine (sigmoid and rectum) at the back and the bladder at the front; In women, the uterus is located anterior to the loops of the small intestine. On the sides: the small intestine is in contact with the cecum and ascending colon on the right side, with the descending and sigmoid colon on the left.
^ The small intestine is supported by the mesentery ; starting from the flexura duodenojejunalis to the transition to the large intestine, it is covered with peritoneum on all sides, with the exception of a narrow strip; where the layers of the mesentery are attached. Due to the presence of the mesentery, the mobility of the small intestine is very significant, but the length (height) of the mesentery throughout the intestine is different, and therefore its mobility is not the same everywhere. The small intestine is least mobile in two places: near the beginning of the jejunum, at flexura duodenojejunalis, and at the end of the ileum, in the region of the ileo-cecal angle. The root of the mesentery of the small intestine (radix mesenterii) has an oblique direction, going from top left to bottom and to the right: from the left half of the body of the P lumbar vertebra to the right sacroiliac joint. The length of the mesentery root is 15-18 cm.
^ Blood supply of the small intestine carried out by the superior mesenteric artery, which gives numerous branches to the small intestine, as well as a number of branches to the right half of the colon. The nerves of the small intestine accompany the branches of the superior mesenteric artery; they are branches of the superior mesenteric plexus.
Diverters LYMPHATIC VESSELS The jejunum and ileum converge at the root of their mesentery, but along the way they are interrupted by numerous mesenteric lymph nodes(nodi lymphatici mesenterici), the number of which reaches 180-200. They are located, according to Zhdanov, in 4 rows. The central nodes through which lymph passes from the entire small intestine (with the exception of the duodenum) are considered to be 2-3 lymph nodes lying on the trunks of the superior mesenteric vessels in the place where they are covered by the pancreas.
^ B – 5
1) Temporal region. Layers: skin, subfiber, superficial fascia, temporal aponeurosis, between the aponeurosis and under the aponeurotic fiber, temporal muscle, temporal bone. Vessels and nerves are located in a radial direction in relation to the crown. Superficial temporal arteries and branches of the facial nerve in the skin/fatty tissue, deep temporal arteries in the thickness of the temporal muscle, medium. shell art. – under the bone in the epidural space. Opening of phlegmon of the temporal region - Fiber, space of the temporal region, boundaries - top and posterior temporal lines, lower zygomatic arch, in front of the zygomatic process, frontal bones.
^ 2) Resection of the small intestine – Indications: tumors, gangrene, strangulated hernias, thrombosis, gunshot wounds. Anesthesia, local anesthesia. Technique: incision along the midline of the abdomen, 2-3 cm from the pubis, + above the navel. A section of the colon is removed into the wound and isolated with gauze pads. The boundaries of resection within healthy tissue are outlined. The resected area is separated from the mesentery by ligating the vessels. A crush is applied to both ends of the removed part of the intestine. clamp, at the ends along an elastic sphincter, then at one end the intestine is cut off by spreading the sphincter and a stump is made, suturing its lumen with a simple through suture from the inside. This is a furrier's seam Sheniden, m\b and a blanket seam. On top of the nodes there is a serous-muscular suture. After removing the resected intestine, a 2nd stump is formed and lateral anastomosis is started. The intestinal wall and loops are connected for 8 cm. another with another row of nodes of small serous-muscular sutures according to Lashber (clean) at a distance of 0.5 cm in the middle of the suture line 0.75 cm from them, the intestinal stack is cut parallel to the suture line. Having also opened the lumen of 2 quiche loops, they begin to sew the inner edges together with a rough continuous wrapping catgut stitch, through all layers. The outer lips are connected with a Schmideni suture (2nd dirty suture), a series of Evil serous-muscular sutures (clean) are applied to the mucosa. The blind ends of the stump are fixed with several sutures to the intestinal wall to avoid their intussusception.
^ 3) Basic surgical instruments : 1-tools for separating fabrics (knives); 2- instruments to stop bleeding (clamps, ligatures); 3- Auxiliary tools (tweezers, hooks) 4- tools for connecting tissues (needle holders)
Rules for using a serviceable instrument: - use for its intended purpose (scalpel cannot be used on bone); - hold tools easily and confidently; - carry out manipulations smoothly; - treat living tissues carefully. A scalpel is the main tool, hold a pen, a table knife, a bow. Scissors: straight, blunt, curved (Cooper), straight, pointed, needle holders, tweezers (anatomical, surgical, clawed)
B – 6
3) Operations other than pancreas Access: upper median laparotomy. The pancreas can be approached in 2 ways: 1) through the gastrocolic ligament, it is dissected, inserted into the lesser omentum, the stomach is pushed up and the colon down. 2) through the lesser omentum by dissecting the transverse gastric ligament. 3) through the mesentery of the transverse colon (for drainage of pancreatic cysts) For acute pancreatitis . Goals: 1) stopping the activation of enzymes and further destruction of the gland by creating a good outflow for secretions. 2) creation of a wide channel for the discharge of sequestered areas of the pancreas. 3) elimination of the inflammatory process in the pancreas. Access: Upper middle laparotomy with transition, if necessary, to the right hypochondrium, a wide tamponade of the omental bursa is performed, drainage of the omental bursa: the gastrocolic ligament is dissected (before this, 0.25% novocaine solution is injected into it), without cutting the pancreatic capsule into the surrounding area the space is injected with 0.25% novocaine solution and 50 thousand units of trasylol. To the pancreas, 5-5 tampons are loosely inserted into the omental bursa and held, the gastrocolic ligament is sutured with separate sutures to the tampons and drainage and sutured to the parietal part of the peritoneum. Operations for pancreatic tumors For cancer of the head, ampullary part of the common bile duct and major nipple of the duodenum, pancreatoduodenal resection is a radical operation. 1) Mobilization of the head of the pancreas, duodenum and the distal part of the stomach along the lesser and greater curvature. 2) intersection of the common bile duct and duodenum. 3) Removal of the head of the pancreas, part of the stomach and the initial part of the duodenum in one block. 4) anastomosis between the common bile duct, pancreatic stump and jejunum, and the remaining part of the stomach. And jejunum (interintestinal anastomosis),
^ 1) Connection and separation of tissues . Disconnection is carried out using cutting tools. Electrotomy - performed with special electrosurgical instruments (using high frequency current) without bleeding. Principle: strictly sequentially cut, must correspond to the course of large blood vessels and nerves, in order to avoid their damage, taking into account the location of the Lasher line - reticular layer II. Technique: 1) fixed with 2 fingers 2) the skin and subcutaneous tissue (to the corresponding fascia) are dissected immediately in one movement 3) lift it with 2 tweezers, make a small hole in the fascia and insert a grooved probe into it through which the facial sac and connective tissue are dissected with a scalpel: 1) bloody (suture) - the cleanest method (silk, catgut, nylon) 2) not bloody (plaster)
2) Breast - part of the body located between the neck and abdomen. Borders: upper - passes along the upper edges of the sternum and clavicle, behind along a horizontal line drawn through the spinous process of the 7th cervical vertebra, lower - passes from the xiphoid process of the sternum obliquely down along the costal arches, behind along a straight line drawn from the distal end of the 12th rib to the spinous process of the 12th thoracic vertebra. Chest muscles: superficial pectoral muscle (functionally refers to the muscles of the shoulder girdle), deep or intrinsic muscles of the chest - external\internal intercostal muscles, transverse chest muscle, diaphragm, tendons of the center of the diaphragm, muscular part of the diaphragm: pectoralis - starts from the inner surface of the xiphoid process. Costal - starting from 7-12 ribs, lumbar - starting at the level of 10 degrees of vertebra, layers: skin, saphenous veins, cutaneous nerves, own fascia, muscles. Topography of the intercostal spaces: filled with intercostal muscles, vessels, nerves, lymph nodes and nodes, which pass in the intermuscular spaces, intercostal canals. The m\costal fissure is bounded above by the costal groove, outside and inside the m\costal mm, and vascular-nerve bundles pass deeper than the external m\costal muscles. The lower 6 m\costal nerves innervate the anterior lateral abdominal wall inflammation of the pleura and lungs abdominal pain. Deep are the costal vessels and nerves - the midcostal mm, and costal cartilages, lined from the inside with intrathoracic fascia, deeper - a layer of loose fiber that separates it from the parietal pleura along its entire length.
^ B -71) V. N. Shevkunenko – his work made it possible to establish differences in the structure of the topography of organs and identify changes in the characteristics that determine these differences with body shape. This facilitates the diagnosis of diseases, clarifies the pathogenesis and course of some pathological processes, explains complications of operations, and contributes to the development of rational surgical approaches and techniques. He published an “atlas of the periphery of the nervous and venous system.”
^ 2) Shoulder joint. Formed by: the head of the humerus and the surface of the scapula. Above the joint hangs a vault, formed by the acramion and the coracoid process. Shoulder joint puncture: can be performed from the front and back surfaces. - in order to puncture the joint, the coracoid process of the scapula is probed from the front, and an injection is made directly under it, the needle is advanced posteriorly, between the coracoid process and the head of the humerus to a depth of 3-4 cm, - from the back, it is passed through a point located below the posterior edge of the apex of the acromion process, in the fossa formed by the posterior edge of the deltoid muscle and the lower edge of the musc supraspinatus, the needle is passed anteriorly towards the coracoid process to a depth of 4-5 cm. The joint is simple, spherical multiaxial, auxiliary formations: labrum, coracobrachial ligament, in front and from the inside the joint is covered by the musc subscapularis, musc corocobrochialis, and the head of the musc biceps; from the outside the joint is covered by the deltoid muscle, near the articular synovial bursa. On top of the greater tubercle of the humerus and the tendon of the supraspinatus muscle - bursa subdeltoidea, the bursa subacromialis (it is higher) communicates with it. These bags do not communicate with the joint cavity. Bursa m. Subscapularis communicates with the joint cavity and connects with the bursa subcorocoidea (at the base of the coracoid process); the joint is attached to the anatomical neck of the humerus. The bursa is strengthened by the lig corocohumerale ligament. 1) at the top - lig gienohumorale 2) lig gienohumorale medium - from the inside 3) lig gienohumorale inferios - below. In the absence of media. ligaments - dislocation in the shoulder joint. The cavity of the shoulder joint is expanded due to 3 inversions: subscapular, axillary and intertubercular. The subscapula is at the level of the anterior upper part of the neck of the scapula (synovial bursa, the backing of the muscle). Between the tuberosities it is formed due to the protrusion of the synovial region. in the m\tubercular groove along the tendon of the long head of the biceps muscle.
^ 3) Indications: kidney rupture, crush injury, kidney stones. Position on the healthy side with a cushion placed under it. Surgical approaches for kidney surgery. They are divided into transabdoninal and extraperitoneal. Transobdominal approaches include midline and pararectal laparotomy. All extraperitoneal approaches are divided into vertical (Simon's incision), horizontal (Pean's incision), and oblique incisions of Fedorov, Bergman - Israel. The most optimal is the Fedorov access. Nephrectomy (standard). Using one of the extraperitoneal approaches, the kidney is exposed and the posterior layer of its outer capsule is dissected. Having isolated the kidney from the fat capsule from all sides, it is removed into the surgical wound. The renal pedicle, vein, artery, posterior wall of the pelvis, and ureter are sequentially exposed. Two ligatures are placed on the ureter and I cross it between it at the border of its upper and middle third. Using a Deschamps needle, 2 silk ligatures are placed under each of the vessels at a distance of 1 cm from one another. The ligatures are cut off, the kidney is removed, drainage is placed, which is removed through the posterior corner of the wound (removed within 5 days). Resection: for tuberculosis, echinococcus, closed injury, gunshot. This is an organ-saving operation. Using the Fedorov approach, the kidney is exposed, the renal pedicle is clamped with an elastic sponge. Use a knife to make wedge-shaped cuts within healthy tissue. Nephropathy : with a foreign body, blind penetrating wounds, stones. The kidney is exposed through an oblique peritoneal incision and brought out. The capsule is dissected, the tissues are separated, and removed with a clamp. Nephrostomy: Rubber drainage is inserted into the pelvis through the holes in the kidney (if outflow from the ureter is obstructed) Nphropexy : wandering prolapsed kidney.
B-8.
^ 1. The doctrine of fascia.
Fascia- This is a connective tissue membrane of various structure and severity, covering mainly the muscles. As well as other anatomical formations. 2 types of fascia: superficial and intrinsic. Superficial- a sheet of varying degrees of thickness, lining the subcutaneous fatty tissue from the inside, making the surface layer mobile in relation to its own fascia. Forms cases for anatomists. formations located in the subcutaneous fatty tissue (veins, arteries, nerves, lymph nodes, facial muscles, internal organs). Own– usually associated with bones, forms cases, septal layers, aponeuroses. Represented by several leaves. The proper fascia fuses with the flat tendons and forms a single anatomical structure with them. Cellular space (fascial) is the space filled with fiber between the sheets of fascia or between the sheet of fascia and the anatomical formation. These common cases are cellular fissures, canals and osteofibrous beds. The cellular fissure is the space located between the organ and the fascia covering it. Channels are usually formed not only by fascia, but also by other dense compounds (ligaments and bones, etc.), sometimes by muscles. Osteo-fibrous beds (fascial, muscle beds) are located in the region of the extremities. They are usually limited to the fascia propria, its septa to the bone, and the bone. Interfascial fatty tissue fills the cellular space between the fascial sheaths of anat formations. It is also located between the fascial sheaths of the anat formations and the parietal fascia.
Borders: upper – line 4 cm above the epicondyles of the shoulder; bottom – 4cm line. below the epicondyle; internal – vertical through the medial epicondyle; external – vertical through the lateral epicondyle. Layers: the skin is thin, the subcutaneous tissue has a lamellar structure, superficial fascia, proper fascia: 2 septa extend from f, cubiti, which continue from the shoulder, thickened in the center due to aponeurosis m. Bicipitalis brachii, muscles: 3 groups each in 2 layers: a) m. Brachioradialis, m. supinator – laterally; b) biceps brachii, m. brachialis - in the center, above the elbow; c) mm. pronator teres, flexor carpi radialis, palmaris longus, flexor carpii ulnaris, deeper and medially m.flexor digitorum superficialis. Walls: tendons m. biceps brachii, m. brachi radialis, sul. Cubitalis anterioses lat. et .medial, epicondyles of the humerus of the saphenous vein, elbow bend. Contents of the cubital fossa: vessels and nerves . Neurovascular bundles: a. collateralis radialis. n. radialis lie on the joint capsule in the gap between mm. brachioradialis et supinator at the level of the lateral epicondyle, the nerve is divided into 2 branches: deep (goes to the posterior region of the forearm in the canalis supinatorius) and superficial (goes to the anterior region of the forearm), a.vv. brachiales lie at the inner edge of the tendon m.biceps brachii, divided into aa. radialis et ulnaris under aponeurosis m. bicipitis brachii. n medianus extends 0.5-1 cm inward from a. brachialis, leaves the area between the heads of the m.pronator teres.
^ 3. Purulent mastitis. Localization of ulcers: subcutaneous, external lobules of the gland, between the fascial capsule of the gland and fascia pectoralis. Op reception: depending on localization. 1) Subcutaneous: opened with linear incisions directed radially in relation to the nipple, the opened cavity is emptied of pus, drained and tamponed with antiseptics, the wounds are not sutured. 2) For deep abscesses and phlegmons, radial incisions are made from the edge of the pigment. spots around the nipple for 5-6 cm, deep. But an arched incision along the skin fold under the mammary gland or parallel to it is better. 3) Retromammary phlegmons (located behind the mammary gland - between it and the pectoral fascia) are opened in the same way, see above. Complete the stage: the opened cavities are emptied of pus and necrosis, drained with loose tampons with an antiseptic solution.
Ticket No. 10
1)TRANSPLANTOLOGY
The field of surgery that deals with tissue and organ transplantation and studies the compatibility of tissues. and preservation of tissues and organs.
Types of transplantation: * autogenous – donor and recipient are the same person
1) isogenic – 1-oval twins
2) syngeneic - related. 1st degree
3) allogeneic – transplantation from person to person
4) xenogeneic – transplantation from living to human
5) prosthetics org. - in and tk. with the use of synthetic materials, etc. inorganic. thing-tv
Types of tissue transplant: free: transplan – moving from one part of the body to another or from one organism to another.
Replantation – affected tissues. and the organs are transplanted back to their original location.
Implantation – transferred to a nearby region.
Non-free: knitted or plastic on the feeding leg, provides for the connection of the cut fabric. flap with the original bed until the moved part grows into a new place.
Skin plastic surgery.
Autologous skin grafting, its free or non-free version, is most often used.
Available: sp - b Yatsenko - Reverden; sp – b Tirsha; sp – b Lawson – Krause.
Non-free: involves the formation of a flap of skin and skin cells that maintain connection with the maternal tissue through the feeding leg.
MUSCLE PLASTY: used for filling bone cavities in patients with osteomyelitis and bronchial fistulas. Regional plastic surgery to close abdominal defects. hernias of the white line of the abdomen, etc.
TENDON AND FASCIA PLASTY: for the east.
Lost f limb, as well as group paralysis
Called muscles. FASCIA to strengthen the joint capsule. TV defect replacement brain. obol, formation of the articular sphincter of the rectum.
BONE PLASTY: for the restoration of a lost f and cosmetic shape of an organ, eliminating a defect in the cranial vault or jaw.
NERVE PLASTY: bringing its ends closer together and eliminating the causes that interfere with regeneration. Operation options: 1st, 2nd suture, nerve transplantation, neurolysis.
VASCULAR PASTY: use of autotransplants (veins, arteries), synthetic prostheses (Dacron, Teflon, etc.). COMPLICATIONS: TRANSPLANT REACTION OF GO IMMUNITY RTI (GVHD) development. in the recipient within 7–10 days of p/e transplantation and is aimed at rejection of the transplant. In RTI, the basis is T-killers, implemented by macrophages and T-lim - you. In order to increase the efficiency of transport, they are carried out non-specifically. immunosuppression.
Blockade of the recipient's immunocompetent system with antimitotic agents, GCs, antilymphocyte sera. 1) replacement of the recipient's hematolymphoid system by total radiation suppression of the lymphoid tissue followed by donor bone marrow transplantation. 2) selective elimination of T cells. with simultaneous stimulation of the activity of T - suppressor cells.
Formed by: the humeral, radial and ulnar os. Consists of 3 joints and one cavity and a common capsule. The joint space is projected anteriorly along the transverse line 1 cm below the later. And 2 cm below the medial epicondyle of the shoulder. The joint capsule is fixed in front to the humerus above the radial and coronoid fossae, behind above the ulnar fossa, to the bones of the forearm along the edge of the articular cartilage. Innervation: n ulnares, radialis
Blood supply: a. brachial is, a collateral’s radialis et ulnaris sup. V. cephalica, v. basilica, v. intermedia cubiti The weak point is the reccessus sacciformis, which is directed into the deep layers of the forearm.
^ 3) OPERATIONS ON THE COLON:* COLON RESECTION
*FECAL FISTULA – COLOSTOMY
*ART OVERLAY. ANUS
Surgeries on the large intestine differ from operations on the small intestine. The thinness and tenderness of the st., its worse nutrition, the presence of an area not covered by the peritoneum, is more infected. Intestinal contents make the suture less reliable. Instead of a 2-row seam, a 3-row seam is used: 1n internal. and two serous-muscular, 3rd row m.b. replaced by fixation to the line of the seromuscular suture of the fatty pendants. ^ COLON RESECTION:
POK - I: cancer, volvulus and intussusception, accompanied by necrosis, megasigma - giant sigmoid colon, extensive intestinal injuries, fistulas, ulcerative colitis.
ANESTHESIA – E: anesthesia or local anesthesia. anesthesia.
^ RESECTION OF THE RIGHT HALF OF THE RIM:
Removal of the cecum with the end section of the ileum, colon (rec) and right section of the transverse colon. The right half of the colon is mobilized, it is cut off and removed along with the upper colon and the terminal ileum. An anastomosis is performed between them (side to side antiperistaltically).
SINGLE-STAGE RESECTION OF THE SIGMOVID COLOUS: The abdominal cavity is opened with a lower midline incision. The sigmoid colon is brought into the wound, approximately in the patol area. process. The first step of the operation is a wedge-shaped excision of the mesentery corresponding to the section of the intestine to be removed. After suppression of the mesentery, the abdominal cavity is carefully isolated with gauze napkins. The sections of the intestine that are supposed to be connected by anastomosis are applied to each other along the edges and sewn together with serous-muscular nodes with sutures - holders that fix them in this position. The intestine is crossed alternately at one and the other end in the transverse direction, the affected area is removed and the lumens are connected end to end.
TWO-STAMP RESECTION OF THE SIGMOVID COLOUS ACCORDING TO GREKOV: The abdominal cavity is opened with a lower midline incision and connected side to side with an anastomosis. A second oblique incision is made in the left iliac region. The area with the pathological process is removed, and the midline incision is sutured. For several days the vessels are ligated and the mesentery is dissected. The affected area is cut off outside the abdominal cavity and the resulting intestinal lumens are closed with a 3-row suture.
Great scientific discoveries
Secrets of the living
Topographic anatomy
The great Russian surgeon and scientist Pirogov is rightfully considered the founder of topographic anatomy.
Nikolai Ivanovich Pirogov (1810-1881) was born in Moscow. When Nikolai was fourteen years old, he entered the medical faculty of Moscow University. To do this, he had to add two years to himself, but he passed the exams no worse than his older comrades.
After graduating from the university, Pirogov went to prepare for professorship at the University of Dorpat. At that time, this university was considered the best in Russia. Here Pirogov worked in the surgical clinic for five years, brilliantly defended his doctoral dissertation and at the age of twenty-six became a professor of surgery.
The topic of his dissertation was the ligation of the abdominal aorta, which had been performed only once before - and then with a fatal outcome - by the English surgeon Astley Cooper. The conclusions of Pirogov’s dissertation were equally important for both theory and practice. When Pirogov, after five years in Depte, went to Berlin to study, the famous surgeons, to whom he went with his head bowed respectfully, read his dissertation, hastily translated into German. The teacher who more than others combined everything that Pirogov was looking for in a surgeon was found in Göttingen, in the person of Professor Langenbeck. The Gottingen professor taught him the purity of surgical techniques.
Returning home, Pirogov became seriously ill and was left for treatment in Riga. As soon as Pirogov got out of his hospital bed, he began to operate. The city had previously heard rumors about a promising young surgeon. Now it was necessary to confirm the good glory that ran far ahead.
He started with rhinoplasty: he cut out a new nose for the noseless barber. Then he remembered that it was the best nose he had ever made in his life. Plastic surgery was followed by inevitable lithotomy, amputation, and tumor removal. In Riga, he operated for the first time as a teacher. From Riga Pirogov went to a clinic in Dorpat.
Here, in 1837, one of Pirogov’s most significant works, “Surgical Anatomy of Arterial Trunks and Fascia,” was born. It was the result of eight years of work, a classic work in breadth and completeness.
There may be a different approach to information about the structure of the human body, and Pirogov writes about this: “... A surgeon should study anatomy, but not like an anatomist... The department of surgical anatomy should belong to a professor not of anatomy, but of surgery... Only in the hands of a practicing physician, applied anatomy can be instructive for listeners. Let an anatomist study a human corpse to the smallest detail, and yet he will never be able to draw the attention of students to those points of anatomy that are extremely important for a surgeon, but may have absolutely no significance for him.”
The reason for the failure of most of the “anatomical and surgical treatises” compiled by Pirogov’s predecessors is the underestimation of the applied significance of anatomy, the avoidance of the “private goal” of serving as a guide for the surgeon. Meanwhile, it is precisely this “private goal”, only it, that everything should be subordinated.
Pirogov, of course, was well acquainted with the works of his predecessors - the prominent French scientists Velpeau and Blunden. I carefully examined the famous Buyalsky atlas. He asks himself the question: “Can a young surgeon be guided in his surgical exercises on a corpse, not to mention operations on the living, by the drawings of the arterial trunks in the best works on surgical anatomy, such as the works of Velpeau and Blunden?”
And he answers decisively: no!
“The usual method of dissection adopted by anatomists ... is not suitable for our applied purposes: a lot of connective tissue is removed that holds the various parts in their relative positions, as a result of which their normal relationships are changed. Muscles, veins, and nerves are removed in the drawings from each other and from the artery to a much greater distance than exists in reality.”
Pirogov criticized Buyalsky’s atlas: “...You see, for example, that in one of the drawings depicting the ligation of the subclavian artery, the author removed the collarbone: thus, he deprived this area of the most important, natural boundary and completely confused the surgeon’s idea of the relative position of the arteries and the nerves to the collarbone, which serves as the main guide during the operation, and the distance of the parts located here from each other.”
The attempts of Velpeau and Buyalsky, brilliant for their time, faded before Pirogov’s new word.
In his essay, Pirogov develops and approves an entire science, surgical anatomy, on the basis of a completely specific and, at first glance, not very voluminous doctrine of fascia. Before Pirogov, almost no work was done on fascia. They knew that there were such membranes, plates surrounding muscle groups or individual muscles, they saw them on a corpse, stumbled upon them during operations, cut them - and did not attach any importance to them, treating them as some kind of “anatomical inevitability.”
Pirogov’s basic idea is quite specific: to study the course of the fascial membranes. He gets to the smallest details and already finds a lot of new things here. Having thoroughly studied the particulars - the course of each fascia - he goes to the general: he deduces certain patterns of relationships between the fascial membranes and the blood vessels and surrounding tissues. That is, it opens new anatomical laws. But he does not need all this in itself, but in order to find rational methods for performing operations, “to find the right way to ligate this or that artery,” as he himself says.
“It’s sometimes not easy to find a vessel,” writes V.I. in his book about Pirogov. Porudominsky. - The human body is complex - much more complex than it seems to a non-specialist who learned about it from posters and diagrams of a school anatomy course. To avoid getting lost, you need to know the landmarks.
Pirogov again scolds (and never tires!) “scientists who do not want to be convinced of the benefits of surgical anatomy”, “famous professors” in “enlightened Germany”, “who from the department speak about the uselessness of anatomical knowledge for a surgeon”, professors whose “way of finding of one or another arterial trunk is reduced solely to touch: “you should feel the beating of the artery and bandage everything from where the blood is splashing” - this is their teaching!!” If the head does not “balance” the hand with extensive anatomical knowledge, the knife of a surgeon, even an experienced one, gets lost like a child in the forest. The most experienced Graefe fiddled for three quarters of an hour until he found the brachial artery. Pirogov explains: “The operation became difficult because Graefe did not end up in the arterial sheath, but in the fibrous bursa.” In order to prevent this from happening, Pirogov studied the fascia in detail, looking for their relationship to the blood vessels and nearby tissues. He showed the traveler-surgeons the most detailed landmarks, set milestones - according to the apt definition of professor of surgery Lev Levshin, he developed “excellent rules for how to go with a knife from the surface of the body into the depths in order to easily and quickly tie up the various arteries of the human body.”
In each section of his work, Pirogov, firstly, outlines the boundaries of the area within which the operation is performed; secondly, it lists the layers that the surgeon goes through, making his way deeper; thirdly, it gives the most accurate operational comments.”
“Surgical anatomy of arterial trunks and fascia” is a text and over fifty tables. Pirogov was always particularly picky about illustrations. He wrote that “a good anatomical-surgical drawing should serve for a surgeon what a guide map serves a traveler: it should represent the topography of the area somewhat differently than an ordinary geographical map, which can be compared with a purely anatomical drawing.”
Pirogov illustrated each operation mentioned in the book with two or three drawings. No discounts, the greatest subtlety and accuracy of the drawings, reflecting the subtlety and accuracy of Pirogov’s preparations - the proportions are not violated, every branch, every knot, jumper is preserved and reproduced. The surgeon will follow such a map without error.
Among those who admired the “Surgical Anatomy of the Arterial Trunks and Fascia” was the famous Parisian professor Alfred Armand Louis Marie Velpeau.
But Nikolai Ivanovich did not rest on this. The usual method of dissection satisfied those who studied the structure of organs. Pirogov brought topography to the fore. He wanted the human body to be as if transparent for the surgeon. So that the surgeon can mentally imagine the position of all parts in a section drawn in any direction through any point of the body.
To find out how different parts of the body are located, anatomists opened cavities and destroyed connective tissue. The air rushing into the cavities distorted the position of the organs and their shape.
However, it was impossible to achieve an accurate cut using the usual method. The arrangement of parts, their relationships, distorted already during the opening of the cavities, were finally changed under the anatomist’s knife. A situation arose that sometimes occurs in science: the experiment itself prevented obtaining the exact results for which it was carried out. It was necessary to find a new way.
There is a legend that connects a random episode from Pirogov’s life with an idea that turned the entire anatomical science onto a new path. “We, ordinary people,” writes one of Pirogov’s followers, “pass without attention the object that gives birth to a creative thought in the head of a brilliant person; “So Nikolai Ivanovich, driving along Sennaya Square, where in winter frozen pork carcasses cut across were usually placed, paid special attention to them and began to apply what he noticed to business.”
Indeed, there is a connection between the sawn-up carcasses on Sennaya Square and a new direction in anatomical research. But Nikolai Ivanovich had the idea much earlier. Talking about his disputes with Amousse in Paris, the surgeon-scientist writes: “I told him the result of my study of the direction of the urinary canal on frozen corpses.” But Pirogov went to Paris as a professor in Dorpat!
Around the same years, Buyalsky made an interesting experiment at the academy: he exposed muscles on a frozen corpse, which was given a beautiful pose; sculptors made a mold and cast a bronze figure - using it, future artists studied the muscles of the body. Consequently, the idea of using cold in anatomical research appeared long before traveling around Sennaya Square. It is difficult to imagine that Pirogov, with his thirst for everything new, with his scope, lived in ignorance. Apparently, Sennaya Square again suggested a method, a methodology, and did not give birth to an idea.
“What path did Pirogov take in seeking accurate data on the topography of the human body? - asks V.I. Porudominsky answers. - He kept the corpse in the cold for two or three days and brought it “to the density of hard wood.” And then he “could treat it in the same way as wood,” without fear of “neither the entry of air after opening the cavities, nor compression of the parts, nor their disintegration.”
Like with a tree! Pirogov sawed frozen corpses into thin parallel plates.
He carried out cuts in three directions - transverse, longitudinal and anteroposterior. A whole series of “disc” records were produced. By combining them and comparing them with each other, it was possible to get a complete picture of the location of various parts and organs. When starting the operation, the surgeon mentally saw transverse, longitudinal, anteroposterior incisions made through one point or another - the body became transparent.
A simple hand saw was not suitable for this purpose. Pirogov adapted another one, brought from a carpentry factory, where they used it to cut mahogany, walnut and rosewood wood. The saw was huge - it occupied an entire room in the anatomical theater.
The room was as cold as outside. Pirogov froze to prevent the corpses from thawing. The work lasted for hours. It would have lost its meaning if each plate of the cut could not be preserved forever and made available to everyone. Pirogov compiled an atlas of sections. The atlas was called: "Illustrated topographical anatomy of cuts made in three directions through the frozen human body." Right there in the cold room, the frozen plates-cuts were covered with glass cut into squares and exactly redrawn in life-size on paper covered with the same grid.”
Pirogov struggled with “ice anatomy” for about ten years. During this time, he discovered another way of “applying cold” to his research - he came up with “sculptural anatomy”. Now no cuts were made. The corpse was frozen even more - “to the density of stone.” And then on the frozen corpse, with the help of a chisel and a hammer, the parts and organs needed for study were exposed from the frozen layers. “When, with considerable effort, it is possible to remove the frozen walls, the thin layers must be thawed with a sponge soaked in hot water until, finally, the organ under study is revealed in its unchanged position.”
If each anatomical atlas of Pirogov is a step in the knowledge of the human body, then “Ice Anatomy” is the pinnacle. New patterns have emerged - very important and very simple. It became known, for example, that, with the exception of three small cavities (throat, nose and ear drum) and two canals (respiratory and intestinal), empty space is never found in any part of the body in a normal state. The walls of all other cavities fit tightly to the walls of the organs contained in them.
Pirogov froze corpses in different poses - then, using saw cuts, he showed how the shape and relationship of organs changed when the position of the body changed. He studied deviations caused by various diseases, age and individual characteristics. I had to make dozens of cuts to find one worthy of reproduction in the atlas. There are a thousand drawings in total in “Ice Anatomy”!
Pirogov's anatomical atlas has become an indispensable guide for surgeons. Now they have the opportunity to operate with minimal trauma to the patient. This atlas and the technique proposed by Pirogov became the basis for all subsequent development of operative surgery.
NIKOLAI IVANOVICH PIROGOV
The name of N. Pirogov occupies one of the first places among the luminaries of advanced medical science of the 19th century. Pirogov's genius showed itself in a number of areas. When studying Pirogov's scientific creativity, we inevitably come to the conclusion that we cannot imagine him only as a clinician, or only as an experimenter, or only as a topographical anatomist. These aspects of Nikolai Ivanovich’s creativity were so intertwined that in all his activities, in any of his work, we see a multifaceted brilliant Russian doctor of the 19th century, the founder of experimental surgery, the creator of topographic and surgical anatomy, the founder of military field surgery, whose works and ideas influenced and continue have a huge impact on the development of Russian and world medical science.
The source of Pirogov’s scientific creativity was, undoubtedly, numerous clinical observations, the accumulation of which began in the surgical department of the Dorpat clinic. Having headed a surgical clinic in Dorpat, Pirogov showed remarkable pedagogical qualities. Already in the “Annals of the Surgical Department of the Dorpat Clinic”, published in 1837, this first report on his practical activities, he wrote that upon joining the department he considered it a rule not to hide anything from his students and always openly admit the mistakes he had made, concerning whether they are diagnosed or treated. Much later, in 1854, in a report on the operations he performed from September 1852 to September 1853, Pirogov wrote in the Military Medical Journal about the Dorpat period of his professorial activity: “All my merit consisted in the fact that I conscientiously told all my errors, without hiding a single mistake, not a single failure, which I attributed to my inexperience and my ignorance.”
The talentedly written “Annals of the Surgical Department of the Dorpat Clinic,” published in two editions (in 1837 and 1839), reflect Pirogov’s very diverse clinical observations. Then, from the time he moved to St. Petersburg and assumed the position of professor at the Medical-Surgical Academy, Pirogov’s surgical activity took on enormous scope, since he was also a consultant to a number of city hospitals, which had more than a thousand beds.
In the middle of the last century, medical science was enriched with a major discovery, which served as a powerful impetus for the development of surgery. We are talking about the introduction of general and local anesthesia into surgery. In introducing ether and chloroform anesthesia into practice, Nikolai Ivanovich Pirogov played a very significant role.
Experiments with ethereal anesthesia carried out by Pirogov on animals, as well as observations on healthy and sick people and on himself, allowed him to express his opinion “about the practical merits of... ethereal vapors as a means of eliminating pain during surgical operations.” Pirogov was the first to develop a method of essential oil anesthesia through the rectum and was the first to apply it in practice. He designed a mask for inhalation anesthesia and a device for administering an anesthetic substance through the rectum. Finally, Pirogov was the first to use anesthesia on the battlefield.
The second remarkable discovery in biology and medicine, which caused a revolution in the treatment of surgical diseases and ensured the flowering of surgical science, was the introduction of antisepsis and asepsis. The honor of introducing the antiseptic method is usually attributed to Lister. But long before Lister, Pirogov attributed the main role to “miasma” in the development of severe complications during injury. Pirogov was more far-sighted than Lister and understood that not only the air contains pathogens of extensive suppuration, but also all objects that come into contact with wound surfaces are fraught with this danger. While still a very young scientist, Pirogov, in his doctoral dissertation devoted to the question of the possibility of ligation of the abdominal aorta, sharply protested against the leaving of various instruments, devices and other foreign bodies in the deep tissues of many surgeons of that time (30s of the last century) (for example , ligatures with a strip of canvas) to stop bleeding or turn off a vessel to eliminate an aneurysm. Pirogov proceeded from the belief that foreign bodies cause a severe suppurative process, inevitably associated with the danger of secondary bleeding.
Creatively exploring the issue of antiseptic solutions that are most gentle on tissue, Pirogov chose a solution of silver nitrate and showed its very beneficial effect on wound healing.
In the treatment of wounds, Pirogov attached great importance to the method of rest. He adhered to the rule of “disturbing the wound as little as possible with bandages.” However, an even greater role was played by the fixed plaster cast proposed by Pirogov, which caused a revolution in the treatment of gunshot and other fractures. Pirogov achieved great skill in applying a plaster cast, continuously improving and turning it into a fenestrated one in cases of complicated fractures. Thanks to the introduction of a plaster cast into the practice of military field surgery, Pirogov narrowed the indications for amputation, leaving it for those cases “when the main artery and main vein are injured, the bone is broken, or the artery is injured and the bone is crushed.” Pirogov’s great merit must be considered his “saving treatment” of wounds, in which amputation gave way to resection and a fixed plaster cast.
There were legends about Pirogov’s high talent as a doctor, who had a broad outlook, rich experience and knowledge, not only among patients, but also among doctors. He was often invited for consultation in complex cases of illness, when it was extremely difficult to make a correct diagnosis and prescribe treatment.
One day, Pirogov, who was with trainee doctors in the German city of Heidelberg, was invited to the Italian national hero Giuseppe Garibaldi, who received a gunshot wound to his right shin in the battle of Mount Aspromonte in August 1862. This was the tenth wound in a row, perhaps the most serious and dangerous in his life.
A non-healing leg wound bothered Garibaldi. For two months he was observed and treated by famous doctors in Italy, France and England, but to no avail. Doctors tried to determine whether there was a bullet in the tissues of the lower leg or not. They carried out painful examinations of the wound - with a finger and a metal probe. After all, X-rays had not yet been discovered. Garibaldi's health condition worsened every day, and there was no clarity in the diagnosis. The question arose about leg amputation.
Due to the sharp deterioration of the patient’s condition, Italian doctors recommended inviting N.I. Pirogov for a consultation, who immediately gave his consent.
Upon arrival in Italy, Nikolai Ivanovich consulted the patient twice, using his research method. He examined Garibaldi, not losing sight of a single detail that characterized the course of the disease. Unlike his Western colleagues, Pirogov did not examine the wound with a probe or finger, but limited himself to a careful examination of the wound area and adjacent parts of the leg.
Recording the results of his observations, Pirogov noted in his diary that “the bullet is in the bone and lies closer to the outer condyle.” The following were recommendations:
“I advised not to rush to remove the bullet, to wait until other phenomena appear, which I defined in a special instruction for Garibaldi... If he had been diagnosed earlier and the bullet was pulled out, then he would probably have to be without a leg... the bullet, sitting near the outer ankle, then approached the hole located near the inner condyle.”
Indeed, as Pirogov foresaw, the bullet was easily removed after some time, without violence.
Believing in his recovery, Giuseppe Garibaldi sent Nikolai Ivanovich a warm letter filled with gratitude:
“My dear Doctor Pirogov, my wound is almost healed. I feel the need to thank you for the heartfelt care you showed me and the skillful treatment you provided. Consider me, my dear doctor, your devoted G. Garibaldi.”
Pirogov’s trip to Italy to see the revolutionary general Garibaldi, and most importantly, the provision of effective assistance to him in treatment, was enthusiastically received by the Russian public and at the same time aroused the discontent of Alexander II, who, however, did not dare to immediately condemn the scientist’s act. But he did it later... In 1866, the venerable surgeon was removed from the leadership of the training of young scientists in Russia.
Pirogov was not only a skilled surgeon, but also an unrivaled general practitioner. One day he was invited to one of the hospitals in Frateshti, where a large number - 11-12 thousand - of the wounded had accumulated. Among this huge mass of people, doctors suspected plague in several patients. Arriving at the hospital, Pirogov, after examining the wounded, moved to the wards where there were patients with suspected plague. Medical student M. Zenets, who was present at the round, later recalled: “Nikolai Ivanovich immediately turned from a surgeon into a therapist. He began to tap and listen in detail to these patients, carefully examine the temperature curves, and so on, and in conclusion he gave a lecture on the Caucasian, Crimean and Danube fevers (malaria), sometimes so strongly reminiscent of the plague.” Pirogov once observed similar patients in Sevastopol and treated them with large doses of quinine.
Pirogov is the creator of the osteoplastic method of amputation. The famous Pirogov osteoplastic amputation of the foot, proposed almost a hundred years ago, played an outstanding role in the development of the doctrine of amputation. On September 19, 1853, through Pirogov’s assistant, prosector Schultz, this operation was reported at a meeting of the Paris Academy of Sciences and it was indicated that it had been performed with complete success in several patients. Pirogov’s operation served as an impetus for the development of a number of new osteoplastic amputations both in our country and abroad. Pirogov’s brilliant idea, the practical implementation of which contributes to the creation of a perfect supporting stump, was further developed during the Great Patriotic War, when Soviet surgeons made a number of valuable proposals related to the treatment of stumps of various parts of the extremities.
Pirogov sought to substantiate each of his proposals either by numerous and persistent studies on corpses when it came to, for example, prompt access to an artery, or by equally numerous experiments on animals. Only after such a deep and thorough study of this or that issue did Pirogov decide to introduce his new proposals into surgical practice, and sometimes, in addition, he entrusted many of his students with the additional development of certain details related to these proposals. One of the little-known facts illustrates Pirogov’s unusual persistence in developing rapid access to the common and external iliac arteries. In the “Annals of the Dorpat Clinic” Pirogov writes that he tested the method of accessing the external iliac artery on corpses several hundred times. This is precisely explained by the fact that he, with the greatest care, developed a method to avoid damage to the peritoneum during such an operation.
Working on compiling an atlas of cuts of frozen corpses, he prepares special cuts in the directions he proposed to expose the external and common iliac arteries. We find in Pirogov’s atlas seven drawings relating specifically to these cuts and clearly showing the advantages of the Pirogov operation. Thus, based on the needs of practice, N. I. Pirogov developed his extraperitoneal access to the iliac arteries, which is an unsurpassed example of brilliant scientific creativity in the doctrine of vascular ligation.
Another example of Pirogov’s extraordinary persistence in scientific research is his numerous cuts of the male pelvis, which were intended to clarify the surgical anatomy of the prostate gland. The fact is that one of the most common operations in the last century was stone cutting (removing a stone from the bladder). This operation was performed mostly using the perineal method for fear of damaging the peritoneum during a suprapubic section. Numerous methods of perineal section often resulted in severe complications, since when dissecting the prostatic part of the urethra and removing the stone from the bladder, the entire thickness of the gland or its base was damaged in some direction. This led to the formation of urinary leaks in the tissue surrounding the prostate gland, with the subsequent development of the inflammatory process. Pirogov performed stone cutting in various ways on numerous corpses, then froze them and made cuts in various directions. In his Anatome Topographica we find 30 drawings relating to this kind of cutting. These drawings convincingly reveal the nature of the injury caused by the tools used in stone cutting. Pirogov, based on a detailed study of the surgical anatomy of the prostate gland, proposed his own method of stone cutting and his own instrument - the lithotome - for this operation.
Pirogov’s outstanding works are “Anatomia chirurgica truncorum arterialiuiTi atguc fasciarum fibrosarum aucto-re Nicolao Pirogoff” with atlas (1837), “Complete course of applied anatomy of the human body, with drawings. Descriptive-physiological and surgical anatomy" (only a few issues were published, 1843-1845) and "Anatome topographica sectionibus per corpus humanum congelatum triplici directione ductis illustrata, auctore Nicolao Pirogoff" (1851 -1859) - brought the author world fame, and the Academy of Sciences in Petersburg awarded Pirogov the Demidov Prize for each of them. In the first of these works (“Surgical anatomy of arterial trunks and fascia”) N. I. Pirogov illuminated the tasks of surgical anatomy in a completely new way; The book made a complete revolution in ideas about the relationship between blood vessels and fascia. Suffice it to say that the laws of these relationships established by Pirogov still play a leading role in the activities of surgeons, especially in wartime conditions, when injuries to blood vessels are often observed.
Topographical Anatomy, Illustrated by Sections Made through a Frozen Body in Three Directions, began appearing in separate editions in 1851 and was completely completed in 1859. The creation of the atlas of cuts, which completed Pirogov’s gigantic work, was a true triumph of Russian medical science: neither before nor after it was created anything equal to this atlas in idea and its implementation. The topography of organs is presented in it with such exhaustive completeness and clarity that Pirogov’s data will always serve as a starting point for numerous studies in this area. As Academician E.N. Pavlovsky rightly writes, “the foundations erected by Pirogov remain and will remain unshakable with all the technical progress of modern and future surgery.”
The atlas of cuts made by Pirogov is today the basis for tomography - a method for diagnosing tumors in organs at the beginning of development.
In the field of pathological anatomy, Pirogov was also one of the largest researchers. Having headed the management of the hospital surgical clinic, the work in which required a lot of time and labor, Pirogov took upon himself to teach a course in pathological anatomy, and during his professorship he dissected (according to I.V. Bertenson) 11,600 corpses, drawing up a detailed protocol for each autopsy.
For the classic study “Pathological anatomy of Asian cholera, with atlas” (St. Petersburg, 1849), based on more than 400 autopsies, Pirogov received the full Demidov Prize. Academician K. Behr’s review of this work gives the following description: “...Especially due to... the strictly scientific method and direct love for truth, this work should be called exemplary, because it belongs to precisely the area in which quite the progress of science is rarely observed.”
How strong an impression the autopsies performed by Pirogov left on those present can be seen from the memoirs of the famous Kazan pharmacologist I.M. Dogel, who decided to become a physician after attending such an autopsy. Dogel writes: “This whole situation, and especially the strictly serious attitude to the matter, or, better to say, the strong passion of the professor himself for his subject, had such an effect on me that I finally decided to devote myself to the study of medical sciences.”
Pirogov studied issues related to the development of the inflammatory process so deeply that he was armed with fairly strong arguments directed against Virchow’s cellular pathology. He subjected this teaching to thorough criticism, emphasizing the leading role in the development of inflammation of the nervous system.
Pirogov's extensive experimental surgical activity began in Dorpat almost immediately after graduating from Moscow University. The topic of his first solid experimental study was the question of ligation of the abdominal aorta. Pirogov devoted his doctoral dissertation, published in Latin and defended in 1832, to the study of the technique and consequences of this operation. He found the arguments in favor of this operation put forward by the famous English surgeon and anatomist E. Cooper, who first performed it on a human in 1817, unconvincing. Cooper, based on several experiments carried out on cats and small dogs that survived after ligation of the abdominal aorta, considered it possible to apply a ligature to the abdominal aorta in a patient suffering from an aneurysm of the iliac artery. Cooper's patient died, like another patient of the surgeon James, who was operated on in 1829.
Pirogov’s study, entitled “Is ligation of the abdominal aorta for aneurysms of the inguinal region an easy and safe intervention?”, aimed to answer the question contained in this title. Pirogov studied the effects of ligation of the abdominal aorta on numerous animals of different species, different ages and different sizes, and the number of experiments aimed at highlighting all aspects of the issue, including the consequences of gradual narrowing of the abdominal aorta, exceeded 60. Pirogov came to the conclusion that, despite blood circulation in the hind limbs that persists during simultaneous ligation of the abdominal aorta in animals, after this operation there is such a severe rush of blood to the lungs and heart that the animals, as a rule, die due to severe dysfunction of these organs.
Pirogov absolutely accurately identified the main, life-threatening complication that develops after ligation of the abdominal aorta. He was primarily interested not in the local circulatory disorders that occur after this operation, but in the effect of ligation of the abdominal aorta on the entire body. Pirogov classically described the clinical and pathological picture of disorders associated with ligation of the abdominal aorta. This is his great merit and undeniable priority.
A large place in Pirogov’s dissertation is devoted to the study of the role of gradual compression of the lumen of the abdominal aorta. And here Pirogov for the first time, through numerous experiments on animals, established that this kind of intervention has significant advantages compared to one-stage (sudden) ligation of the aorta: experimental animals tolerate such an effect much more easily. Based on the conviction that it was inadmissible to leave all kinds of instruments in deep tissues, Pirogov developed an original method by which he gradually narrowed the lumen of the abdominal aorta in animals. Its essence lies in the fact that he brought the ends of the ligature applied to the aorta out and tied it to the Buyalsky tourniquet, by rotating the moving part of which you can twist the ligature and thereby narrow the lumen of the vessel. By gradually tightening the ligature over several days, Pirogov achieved complete or almost complete obstruction of the abdominal aorta, and in these cases, severe complications from the lungs and heart often did not develop, which, as a rule, led to the death of animals (calves, sheep) after a single-stage ligation abdominal aorta. With the gradual narrowing of the abdominal aorta, it was possible to prevent the development of paralysis of the hind limbs in animals.
Subsequently, Pirogov transferred his observations of animals to the clinic and expressed similar considerations regarding ligation and other large arterial trunks, such as, for example, the common carotid artery.
The question to what extent and due to which arteries the roundabout circulation develops after ligation of the abdominal aorta first received proper coverage in Pirogov’s experiments, partly described in the dissertation, partly discussed in the “Annals of the Dorpat Clinic”.
An interesting question, subjected to serious consideration in Pirogov’s work and receiving fundamentally correct coverage for the first time, concerns the cause of paralysis of the hind limbs, observed in most animals after ligation of the abdominal aorta. Pirogov expressed the following opinion on this matter: “The cause of paralysis, which we observe on the limbs after ligation of the aorta, should be sought, apparently, partly in the spinal cord itself, partly in the endings of the nerves.”
Before Pirogov, it was generally accepted that the cause of this paralysis was only a disorder in the spinal cord. This point of view was held, for example, by the French physiologist Legallois, famous at the beginning of the 19th century. Pirogov, with a series of his experiments, refuted the point of view of Legallois, based on a single experiment that was carried out by this physiologist on a rabbit. Pirogov showed that the degree of restoration of blood circulation in the spinal cord after ligation of the abdominal aorta varies in different animals.
The question of whether serious changes actually occur in the spinal cord after ligation of the abdominal aorta has not yet been finally resolved. In any case, the most recent data suggest that after such an operation, dead animals may experience a breakdown of the white and gray matter in the lumbar part of the spinal cord. Therefore, there is every reason to agree with Pirogov that the cause of paralysis of the hind limbs is changes in both the peripheral nerves and the spinal cord. At least with regard to the brain, Soviet scientists have already convincingly shown that its anemia, under certain conditions, can be the cause of severe irreversible changes in brain tissue, leading to the death of animals.
Having studied the detailed topography of the abdominal aorta in humans and animals, Pirogov proved that a more advantageous, although not always easy, access to the aorta is extraperitoneal, in which this vessel is exposed by detachment of the peritoneal sac. In the pre-antiseptic period, such access had undoubted advantages over the transperitoneal approach, in which exposure of the aorta is achieved through a double dissection of the peritoneum, which is part of both the anterior and posterior abdominal walls. This last path was chosen, by the way, by E. Cooper, who ligated the abdominal aorta in a patient suffering from an aneurysm of the iliac artery. After publishing Pirogov's dissertation, Cooper stated that if he had to ligate the abdominal aorta in a person again, he would choose the extraperitoneal route.
These are the remarkable observations that Pirogov made at the dawn of his brilliant scientific activity. Pirogov’s indisputable priority in a number of issues of circulatory pathology is evident when analyzing the scientific work of Pirogov, as well as his predecessors and contemporaries. His convincing conclusions played a significant role in the further development of world surgical science. Suffice it to say that the method of gradual compression of the abdominal aorta and narrowing of its lumen developed by Pirogov attracted the attention of surgeons from all countries. Pirogov’s idea was also reflected in the dissertation work of the outstanding Soviet scientist N.N. Burdenko, who used gradual shutdown of the portal vein, the sudden ligation of which in animals leads to their death. The famous Soviet surgeon Yu. Yu. Dzhanelidze during the Great Patriotic War created a universal vascular compressor, which makes it possible to gradually compress large vessels such as the subclavian or carotid artery, which seems to be very important for the development of collateral circulation in gunshot aneurysms. With the help of this device, it was possible to cure the wounded who suffered from severe aneurysms without surgical intervention.
Pirogov was interested in issues of vascular pathology and collateral circulation throughout his entire scientific career.
With these widely and deeply conducted experimental studies, Pirogov for the first time showed the importance of the evolutionary approach in resolving a number of pathological issues: before him, there were no works in which the experimental study of certain problems was carried out on numerous animals of different species. Pirogov conducted experiments with ligation of the abdominal aorta on cats, dogs, calves, sheep, and rams, and performed ligation of other vessels on horses.
Just the enumeration of the questions that interested Pirogov amazes with the exceptional breadth and depth of the creative ideas of his genius. These questions are: transection of the Achilles tendon and the healing processes of tendon wounds, the influence of animal air introduced into the veins (issues of air embolism), pneumothorax and the mechanism of lung prolapse in chest injuries, injuries to the abdominal viscera and intestinal suture, the effect of cranial trauma and much more.
Pirogov should be recognized as the founder of experimental surgery: before him, medical science did not know so deeply and with such coverage of research undertaken by one surgeon and aimed at studying various problems related to the needs of the clinic.
Pirogov, with his grandiose experimental and surgical activities, determined the main ways for the development of this type of research: firstly, the closest connection with the clinic and pathological anatomy, and secondly, an evolutionary approach to the study of pathological issues. This was one of those directions in the development of Russian medical science that determined its independent, original character and which brought it remarkable success. Soviet medical workers do not for a minute forget the glorious names of those outstanding Russian doctors who, with their scientific feats, made an invaluable contribution to the treasury of world medical science and greatly contributed to its development.
