Искусство, ремесло и наука ампутации конечностей. Часть 2. Ремесло ампутации: от Амбруаза Паре до Пьера Диониса (конец XVI – начало XVIII в.)

Since the XVI century until the beginning of the XVII century an operation of limb amputation has undergone changes and improvements that have affected all its aspects: preparation for carrying out, the technique of performing and postoperative treatment of patients. The invention of the ligature (1552) and the tourniquet (1674) became revolutionary. Wet and dry gangrene, extensive trauma to soft tissues and bones, traumatic limb amputation and osteomyelitis were considered of indications for amputation. The deontological and legal framework for amputation was developed, including the patient’s consent to the operation and the awareness of relatives about its outcomes. The article presents an instrumental and dressing apparatus of the XVII century for the operation; medicines used for general and local treatment of the patient before and after truncation of the stump; sedation and pain relief issues; technique of circular and one soft tissue flap (1679) amputation; the choice of tissue dissection level; methods of stopping bleeding (astringents, pressure bandage, cauterization, ligation and stitching of blood vessels); a method of stitching a stump wound, applying a bandage on it and strengthening it; postoperative management (regimen and diet, dressing change, staged wound treatment, complications); the phenomenon and causes of “phantom limbs”.С XVI до начала XVIII в. операция ампутации конечностей претерпела изменения и усовершенствования, которые коснулись всех ее сторон: подготовки к проведению, техники выполнения и послеоперационного лечения больных. Революционными стали изобретение лигатуры (1552) и турникета (1674). Показаниями к ампутации считали влажную и сухую гангрену, обширную травму мягких тканей и костей, травматическую ампутацию конечности, остеомиелит. Были разработаны деонтологические и правовые основы ампутации, включая согласие больного на операцию и информированность родственников об ее исходах. В статье представлены инструментальный и перевязочный аппарат XVII в. для проведения операции; лекарства, применявшиеся для общего и местного лечения больного до и после усечения члена; вопросы седации и обезболивания; техника круговой и однолоскутной (1679) ампутации; выбор уровня рассечения тканей; способы остановки кровотечения (вяжущие средства, давящая повязка, прижигание, перевязка и прошивание сосудов); способ зашивания раны культи, наложения на нее повязки и ее укрепления; послеоперационное ведение больного (режим и диета, смена повязок, этапное лечение раны, осложнения заживления); феномен и причины «конечностей-призраков»

Искусство, ремесло и наука ампутации конечностей1 Часть 1. Искусство и ремесло ампутации: от Гиппократа до Амбруаза Паре (V в. до н. э. – XVI в.)

Limb amputation is one of the oldest and most famous operation in surgery. Over the millennia, the tools for its implementation and the technique for its perfomance have been constantly improved. In part 1 of the article, using historical, chronological and dialectical methods, as well as the method of comparative content analysis a number of printed (Hippocrates, V-IV centuries B.C.; Celsus, I century; Abu-alQasim, XI century; A. Paré, XVI century, etc.), material (prostheses, surgical instruments) and visual (engraving, painting, etc.) sources, the circumstances and features of the emergence and development of instruments and techniques for limbs amputation from antiquity to the era were studied and recreated Renaissance. The main indication for amputation was the limb death (gangrene), as well as significant tissue trauma caused by cold or firearms (since the XIV century). The limb was truncated (or isolated) with a circular section along the demarcation line (in ancient times) or within healthy tissues (in the Middle Ages). The operation was carried out under a tourniquet applied above the level of amputation; healthy tissues were shifted proximally; sometimes a second tourniquet was applied - below the cut-off level. Anesthesia was achieved by operating in a state of painful shock, after bloodletting, or by applying a tight ligature (tourniquet). Bleeding was stopped with the surgeon's finger, cauterization or vessel cutting of, ligature of one vessel or the entire bleeding tissue (en masse), suturing of the bleeding vessel (A. Paré), as well as astringents and a bandage. The wound of the stump was left open or brought together with sutures. A major stage in the development of amputation was the work of A. Paré (XVI century), who improved instruments (in particular, clamps for stopping bleeding), the technique of the operation, and pain relief during its performance. If in the Ancient World and in the early Middle Ages amputation was life-threatening, available only to a few of the most skilled doctors, was performed relatively rarely and was akin to art, then after its development in the XIII–XIV centuries. barbers began to perform it everywhere, routinely and gradually turned into a craft. Further development of indications for amputation, techniques for its implementation and the transformation of this operation from a craft into a science from the XVII century. until the middle of the twentieth century will be reflected in part 2 of this article.Ампутация конечности – одна из самых древних и самых известных операций в хирургии. На протяжении тысячелетий инструменты для ее выполнения и техника ее проведения постоянно совершенствовались. В части 1 статьи при помощи исторического, хронологического и диалектического методов, а также методом сравнительного контент-анализа ряда печатных (Hippocrates, V–IV вв. до н. э.; Celsus, I в.; Abu-al-Qasim, XI в.; A. Paré, XVI в. и др.), вещественных (протезы, хирургические инструменты) и визуальных (гравюра, живопись и др.) источников изучены и воссозданы обстоятельства и особенности возникновения и развития инструментария и техники ампутации конечностей с древности до эпохи Возрождения. Основным показанием к ампутации было омертвение конечности (гангрена), а также значительная травма тканей, нанесенная холодным или огнестрельным (с XIV в.) оружием. Конечность усекали (или вычленяли) круговым сечением по линии демаркации (в древности) или в пределах здоровых тканей (в Cредние века). Операцию проводили под жгутом, наложенным выше уровня ампутации; здоровые ткани сдвигали проксимально; иногда накладывали второй жгут — ниже уровня отсечения. Анестезии достигали, оперируя в состоянии болевого шока, после кровопускания или наложением тугой лигатуры (жгута). Кровотечение останавливали пальцем хирурга, прижиганием или пересечением сосуда, лигатурой одного сосуда или всей кровоточащей ткани (en masse), прошиванием кровоточащего сосуда (A. Paré), а также вяжущими средствами и повязкой. Рану культи оставляли открытой или сближали швами. Крупным этапом в развитии ампутации стали труды A. Paré (XVI в.), усовершенствовавшего инструменты (в частности, зажимы для остановки кровотечения), технику операции и обезболивание при ее выполнении. Если в Древнем мире и в раннем Средневековье ампутация была жизненно опасна, доступна лишь немногим наиболее искусным врачам, выполнялась сравнительно редко и была сродни искусству, то после ее освоения в XIII–XIV вв. цирюльниками (в том числе полевыми) она стала выполняться повсеместно, рутинно и постепенно превратилась в ремесло. Дальнейшее развитие показаний к ампутации, техники ее выполнения и превращение этой операции из ремесла в науку с XVII в. до середины ХХ столетия будет отражено в части 2 настоящей статьи

Академик РАМН Михаил Ильич Кузин и его деятельность во главе Института хирургии им. А.В. Вишневского АМН СССР (к 100-летию со дня рождения)

The article is dedicated to RAMS Academician M. I. Kuzin (1916–2009) and to his work as the head of the A. V. Vishnevsky Institute of Surgery of the AMS of the USSR (1976–1988). It is shown that M. I. Kuzin, becoming the head of the main surgical Research Institute of the country, not only developed many surgery areas, which were initiated by his predecessor – the academician of the AMS of the USSR – A. A. Vishnevsky and some exponents of his school (particularly, these are cardiac, thoracic and abdominal surgery), he extended some of areas (for example, peptic ulcer surgery, vast burns and wounds surgery), but also he laid the basis for new areas (liver surgery, endoscopic surgery, and so on). In general, 12-year-activity of M. I. Kuzin as the head of the A. V. Vishnevsky Institute of Surgery of the AMS of the USSR (and then he delegated his directorship to the academician of the AMS of the USSR V. D. Fedorov) was very profitable for progressive advance of collective, and this helped the Institute to become the “Collective of high culture” in 1979 and “The Exemplary Institution of Moscow” in 1981.Статья посвящена академику РАМН Михаилу Ильичу Кузину (1916–2009) и его деятельности в качестве директора Института хирургии им. А. В. Вишневского АМН СССР (1976–1988). Встав во главе ведущего хирургического научно-исследовательского института страны, М. И. Кузин не только развил многие направления хирургии, начатые его предшественником, академиком АМН СССР А. А. Вишневским, и представителями его школы (в частности, сердечную, торакальную и абдоминальную хирургию), и углубил некоторые из них (например, хирургию язвенной болезни желудка и двенадцатиперстной кишки, хирургию обширных ран и ожогов), но и заложил основы новых направлений (хирургия печени, эндоскопическая хирургия и др.). В целом 12-летняя деятельность М. И. Кузина на посту директора Института хирургии им. А. В. Вишневского АМН СССР, который в 1988 г. он передал академику АМН СССР В. Д. Федорову, плодотворно сказалась на поступательном движении коллектива вперед, что позволило Институту в 1979 г. стать «Коллективом высокой культуры», а в 1981 г. – «Образцовым учреждением города Москвы»

НЕСГИБАЕМЫЙ, НЕУЕМНЫЙ ВЛАДИМИР ДЕМИХОВ

To the 100th anniversary of Vladimir Petrovich Demikhov(к 100-летию со дня рождения

PHENOMENON OF DEMIKHOV. In the Sklifosovsky Institute (1960–1986). The Moscow dreamer (autumn of 1960)

On September 1, 1960, V.P. Demikhov was taken in the staff of the Sklifosovsky Research Institute for Emergency Medicine. But earlier, in the summer of that year, he talked at a meeting of the Academic Council of the Institute about his achievements in transplanting vital organs in warm-blooded animals in experiment, and outlined a plan for their implementation into clinical practice. In his opinion, the N.V.Sklifosovsky Institute for Emergency Medicine best suited for that purpose. However, the first months of his work in a new place showed that the Institute was neither morally nor organizationally ready to perform clinical organ transplantations. The his idea of mammarocoronary anastomosis developed in 1953 was not heard either

PHENOMENON OF DEMIKHOV. "Transplantation of vital organs In experiment" (1960). Homoplastic organ transplantation: Transplantation of an additional heart, heart-and-lung transplantation

The article (the second of five) reviews the beginning of the Third Chapter from the monograph by V.P.Demikhov "Transplantation of vital organs in the experiment" (M.: Medgiz Publisher, 1960), the chapter covering the issue of homoplastic organ transplantation. The article discusses the results of V.P. Demikhov's work to create the following models: an additional isolated heart, an additional heart with a lung lobe, and a heart in combination with both lungs. Basing on the generally accepted "critical" timing of grafted transplant rejection onset (7th, 14th, or 21th days), Demikhov regarded the graft survival for longer as the fact of the successful engraftment, and every prolongation of the recipient's life with the donor organ as the win over the nature convinced him of the right path chosen. V.P. Demikhov performed the transplantation of the "heart-lungs" complex to simplify the separate anatomical transplantation of these organs and believed that the improvement of surgical methodology and techniques would enable him to achieve their complete engraftment, aiming at further translation the most successful experimental results from the laboratory into the clinical practice

PHENOMENON OF DEMIKHOV. In the Sklifosovsky Institute (1960–1986). Scientifc Revolution in Transplantation (1960–1964). Achievements of the USA and the USSR in the feld of transplantation and transplant immunity (1962)

Correspondence to: Sergey P. Glyantsev, Prof., Dr. Med. Sci., Head of the Department of the History of Cardiovascular Surgery at A.N. Bakoulev National Medical Research Center for Cardiovascular Surgery, Head of the Medical History Unit within the Medical History Department at N.A. Semashko National Research Institute of Public Health, e-mail: [email protected] Received: August 08, 2018 Accepted for publication: September 12, 2018 The article presents the evidence of a scientific revolution in transplantology that occurred in the world in 1960-1964 with the shift of the paradigm from the impossibility of homoplastic organ transplants to the hope on their feasibility. It began in 1960 with awarding the Nobel Prize to P. Medawar and F. Burnet for the discovery of artificial immunological tolerance, it had its continuation in 1961–1962 with the advances in experimental transplantation of vital organs undertaken in conditions of mechanical circulation (R. Lower, N. Shumway) and immunosuppression (K. Reemstma), and completed with human transplantations of lung in 1963 and of heart in 1964 (J. Hardy). In those years, the concept of mechanical support for an ill heart by using an implanted mechanical assist device was developed and introduced (1963). But even against that background, V.P. Demikhov's achievements in homologous organ transplantation and the development of biological techniques to overcome tissue incompatibility looked impressive. His highest achievement was the transplantation of a supplemental heart to the dog Grishka in June 1962, and the dog survived with it for 141 days. However, after the discoveries in the field of transplantation immunity, the train of experimental transplantation where V.P. Demikhov was riding, began picking up speed very quickly, and the Soviet surgeons were to jump on its footboard