Diagnosis of a narrow pelvis

Posted on April 26, 2020  in Pelvic diseases

Diagnosis of a narrow pelvis is usually not difficult. Already a careful external examination of the pregnant woman is often a doctor vozpikaet thought of having a narrow pelvis: general physical hypoplasia, short stature ( mepype 150 cm), sharp lordosis, signs of childhood rickets (square skull, chicken breast, sablevidnoizognutye leg and so on.). Scoliosis, kyphosis, shortening of one of the legs, ankylosis, dislocations of the hip joints always signal the presence of certain pelvic deformities. The doctor receives very valuable data upon careful examination and measurement with a centimeter tape of the Michaelis rhombus . In well-built women with a normal pelvis, the rhombus has the shape of an almost regular square set on one of the corners (A. Yu. Lurie). With a uniformly narrowed pelvis, the transverse size of the rhombus is reduced by 1-1.5 cm, that is, it is 8-7.5 cm (instead of 9 cm); the longitudinal (vertical) size is slightly increased compared to the norm – 11 cm. The upper and lower corners of the rhombus approach acute, and the side corners approach obtuse. In other words, the rhombus is slightly flattened vertically. With a flat basin, on the contrary, the longitudinal size of the rhombus is reduced by 3-4 cm, while the transverse remains unchanged. Sometimes the upper half of the rhombus is so flattened horizontally that its upper corner disappears, and the rhombus turns into a triangle with a vertex facing down.

The asymmetrical shape of the rhombus usually indicates an oblique pelvis.
If you suspect a narrow pelvis, all its dimensions must be measured especially carefully and, moreover, repeatedly: during pregnancy and at the beginning of the first stage of labor. The fact that the pelvis during pregnancy peskolko increases obviously under the influence of hormonal influences: the true conjugate is extended to 0.5 cm In addition, during pregnancy is still impossible to judge the size of the fetal head at the time of delivery and its appropriate size. pelvis.

If a narrow pelvis is suspected, along with the usual measurement of the external dimensions, it is determined and compared with the following indicators.
1. The circumference of the pelvis. It is measured at the upper corner of the Michaelis rhombus , iliac scallops and the upper edge of the symphysis. Normally, the circumference of the pelvis is 85 cm. If its size approaches 75 cm, this indicates a significant narrowing of the pelvis. 2. Lateral conjugates (right and left). The measurement is made with a tazomer between the anterior and posterior iliac spine on each side; normal sizes of the lateral conjugates are 14.5-15 cm. Shortening them to 13 cm indicates a significant narrowing of the pelvis. 3. The oblique dimensions of the pelvis – the distance along the tazomer from the anteroposterior iliac spine of one side to the posterior- superior spine of the other. Each oblique size of a normal pelvis is 22.5 cm. A symmetrical decrease in these sizes is observed with a uniformly narrowed pelvis. The difference between the right and left oblique dimensions indicates the asymmetry of the pelvis. 4. The height of the pubic joint. It is determined by capturing with the thumb and forefinger the upper and lower edges of the pubic joint (A. Yu. Lurie). The distance between the toes was measured tazomera (in normo it is equal to 4-5 cm). The higher the pubic articulation, the smaller the true conjugate . At high lonnom articulation on the size of the true conjugates need to take 0.5 cm. Thus, if in normo true conjugate less diagonal average of 1.5 cm, the flat pelvis it is smaller by 2 cm. The diagonal conjugate is measured at the first intravaginal study of women in childbirth. Suspicion of a narrow pelvis is itself an indication for immediate vaginal examination with the obligatory measurement of diagonal conjugates . Simultaneously with the measurement, conjugates examine all the piles of the pelvis with your fingers to get an idea of ​​the structure, shape and capacity of the pelvis. 5. About the thickness of the bones of the woman in childbirth (and therefore about the thickness of the bones of the pelvis) gives an idea of ​​the Soloviev index – the value of the circumference of the wrist of the woman in labor , measured with a centimeter tape, write the styloid process. In norm, the Soloviev index is 14.5-15 cm. If the wrist thickness is less, then the bones of the woman, and therefore the pelvic bones are thin, and the capacity of the pelvic cavity, all other things being equal, will be greater. With a wrist thickness of 16 cm or more, the capacity of the pelvis with the same external dimensions will be less due to the thickness of the bones. 6. The angle of inclination of the pelvis , determined by a special tazomer , is also important : the larger the angle of inclination of the pelvis (on average it is 60 °), the greater the true conjugate , which with a narrow and especially with a flat basin is a favorable indicator. 7. The size of the fetal head can be judged approximately by the length of the fetus and the diameter of the head, measured with a tazomer across the entire thickness of the abdomen, which is very inaccurate, and in cases of an excessively thick, strained abdominal wall. Therefore, the following two methods for determining the relationship between the fetal head and the mother’s pelvis are of great practical importance. Sign of Vasten . The doctor, standing on the side of the woman in childbirth, puts a palm on her pubis, straightening her fingers, and then moves the brush with a sliding motion upward on the head. In this case: 1. The edge of the palm of the hand of the obstetrician, when moving upward, encounters, as it were, a hill protruding above the upper edge of the symphysis. This is the head of the fetus; it is pressed to the symphysis and is not inserted, since its dimensions do not correspond to the dimensions of the pelvis. Therefore, it will stand, as if hanging over the symphysis. This position is referred to as positive vasten . 2. The edge of the brush, when moving upward, as if jumps from the upper edge of the symphysis to the fetal head, since the head is freely inserted into the pelvic entrance and its surface is located below the surface of the symphysis; in such a case they say: ” negative vasten “, which indicates the absence of any mismatch between the size of the fetal head and the entrance to the mother’s pelvis. 3. The edge of the hand freely moves upward from the symphysis, to the fetal head, remaining in the same plane, since the surface of the symphysis and the fetal head, firmly pressed to the entrance to the pelvis (but not yet inserted), are also in the same plane. This polo { ix called ” Vastu level.” It indicates the presence at the moment of some slight mismatch between the pelvis and the head, which, as a rule, is overcome with the development of good labor and a pronounced configuration of the fetal head. There is reason to believe that the head will pass the entrance of the narrowed pelvis. The Vasten sign is one of the very important criteria for assessing pelvic functional failure. However, its character can only be judged with a fixed fetal head. For greater persuasiveness of the results obtained using the Vastep method, the Zapgemeister method is used . In a standing position, women in labor determine the external conjugate of the pelvis with a tazomer ; remembering the figure obtained and without shifting the buttons of the posterior jaw of the tazomere , the button of the front jaw is moved from the upper edge of the symphysis to the most prominent point of the underlying fetal head.

 If the resulting figure is less than the magnitude of the external conjugates , the prognosis is good; if more, the forecast is bad, if the numbers are the same, the forecast is uncertain: everything will depend on the nature of labor and the configuration of the head. We repeat: with a narrow pelvis during childbirth, repeated vaginal examination is necessary. In this case, the ratio of the fetal head with the entrance to the pelvis, asynclitism and its types, degree of head configuration, condition and location of the fontanelles, insertion of the head, presence and location of the birth tumor, features of the pelvis (determination of the true conjugates , degree of coccyx mobility, the presence of exostoses, the nature of the promontory are determined , capacities and forms of the sacral cavity ). Without knowledge of all these data, proper management of labor is impossible. At I and II degrees of narrowing of the pelvis, delivery through the natural birth canal is possible in most cases, but under the following conditions (according to A. Yu. Lurie): 1) the circumference of the pelvis is at least 75-80 cm; 2) lateral conjugates – not less than 14 cm; 3) Soloviev index – not more than 14 cm; 4) the direct and transverse dimensions of the outlet of the pelvis – not less than 10 cm; 5) bosom height – no more than 5 cm; 6) the angle of inclination of the pelvis approaches 60 °; 7) The direct resolution of the head (on paruzhnomu definition tazomera ) – no more than 10-11 cm; 8) ” vasten is negative” or “level”; 9) “ Tsangmeister is positive” in favor of external conjugates . To this it is necessary to add carefully analyzed data on the size of the fetus, the degree of configuration and the nature of the insertion of the head; strength, duration, regularity and productivity of labor pains; amniotic fluid; the state of the fetus (often listening to his heartbeat or, better, with the help of phonoelectrocardiography ); the general condition of the woman in labor, the degree of her fatigue.

Cervical rupture

Posted on April 25, 2020  in Pelvic diseases

According to our data, out of 10,000 puerperas, cervical tears were observed in 27.6% of primiparous and in 5.3% of multiparous. In multiparous, cervical ruptures are rarely observed, mainly if the fetus is large or surgical delivery is performed .
Rupture of the cervix, as a rule, occurs from the back of the head (in 78%) and less often from the front of the fetus. One-sided cervical ruptures were observed in 68.2% of the prostitutes , two-sided in 29.4%, multiple cervical ruptures and crises in 2.4% of the total number of identified ruptures. In multiparous spontaneous births, one-sided ruptures prevail.
Bleeding from the cervix, requiring urgent interventions, occurred in 3.6% of women in labor. In the rest, ruptures of the neck were revealed during routine examinations of the birth canal. In the group of women with bleeding from the birth canal, cervical trauma as a cause of bleeding takes a small proportion and amounts to 3-7%, according to various large obstetric hospitals.
Bleeding from the cervix arises, as a rule, from arterial branches. Blood with its bright red color differs from venous blood flowing from the vessels of the uterus. With cervical ruptures that extend to the tissues of the arch or lower segment of the uterus, bleeding can be from damaged large venous vessels, and then the blood in appearance does not differ from the flow from the uterus.
Diagnosis of bleeding with ruptures of the cervix but presents difficulties and is carried out by examining the cervix using mirrors. Neck capture fenestrated forceps and completely degrade the bottom. Consistently inspect its entire surface. If a rupture is detected (it is usually localized on the lateral surface of the cervix), it is necessary to carefully examine its upper border and, if possible, the lower section (segment) of the uterus above the rupture site. For this purpose, mirrors with lighting made of transparent plastic are successfully used. We always conduct a digital examination of the lower segment of the uterus and the area above the rupture of the inner surface of the cervix. This is necessary to recognize incomplete ruptures of the lower segment of the uterus, which may not extend to the tissues of the vaginal fornix.
After analyzing a large number of births that ended fatally as a result of acute anemia (data from obstetric hospitals in Ukraine), we identified cases when a deep rupture of the cervix was timely detected, stitches were sutured, and bleeding continued due to a rupture of uterine tissue above a visible rupture of the cervix.
Linear ruptures of the cervix can sometimes be accompanied by stratification, rupture or crushing of the muscles of the inner surface of the cervix. These lesions are easily detected when examining the inner surface of the neck. Bleeding from the cervix is ​​stopped by imposing knotted catgut sutures transverse to the length of the neck rupture after preliminary excision of the neck tissue. As a result of refreshing the edges of the gap, the healing process of the neck by primary intention is significantly increased. Catgut or silk sutures are applied , and the first suture must be applied to the neck tissue at the upper rupture angle or even higher, within intact tissues. Silk sutures should be removed on the 8-9th day after birth.

Uterine Tears

Uterine ruptures, regardless of the size of the damage (complete, incomplete), are usually accompanied by bleeding, although the amount of blood loss is not always proportional to the degree of tissue damage. If arterial or venous vessels of large diameter rupture together with the uterine muscle, bleeding can be significant, even fatal. If vessels of small diameter that are within the muscle tissue rupture , they can be squeezed by a contracted uterus and bleeding in this case will be small.
With uterine ruptures, external bleeding (blood flows from the genitals) and internal bleeding are distinguished when the bleeding accumulates in the abdominal cavity (with a complete rupture), in the peritoneal and pelvic tissue (with an incomplete rupture). The absence of visible bleeding can lead to a gross error in assessing the patient’s condition and ultimately to her death due to an unrecognized rupture of the uterus.

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Gunshot wounds to the pelvis and pelvic organs

Posted on April 21, 2020  in Pelvic diseases

Classification of gunshot wounds of the pelvis

Among the gunshot wounds of the pelvis are:

1) soft tissue injuries of the pelvic region,

2) soft tissues and pelvic bones,

3) the pelvis and pelvic organs (intraperitoneal and extraperitoneal).

With injuries of the soft tissues of the pelvis, damage to large blood vessels is possible, accompanied by dangerous internal or external bleeding. Damage to the sciatic nerve is manifested by paresis, paralysis and various types of sensory impairment. The proximity of the anus and the presence of large muscle masses in the wound area predispose to the development of severe wound infection, including anaerobic infection. Gunshot fractures of the pelvic bones without damage to internal organs. By the nature of the damage to the bone, fractures are distinguished by comminuted , perforated, marginal, tears and cracks. Localization – fractures of the ilium, pubic, sciatic bones, sacrum, sacroiliac joints, tailbone. Splinter fractured fractures predominate. Gunshot fractures are mainly classified as severe injuries, often complicated by massive bleeding and shock. When diagnosing pelvic gun fractures, the location of external wounds and subcutaneous hematomas, the projection of the wound canal and the localization of pain when pressing on the bone protrusions should be taken into account. Pubic bone fractures are characterized by pain that occurs at the fracture site when pressure is applied to the symphysis, sciatic bone fractures are recognized when pressure is applied to the ischial tubercles. In case of fractures of the anterior part of the pelvic ring , the symptom of a “stuck heel” is characteristic – it is impossible to raise a straightened leg. Coccyx fractures are better detected by rectal examination. X-ray examination of the wounded allows you to clarify the diagnosis. Gunshot wounds of the pelvis are often complicated by a wound infection: abscesses, phlegmon of the pelvic tissue, pelvic osteomyelitis, etc. acetabular fractures can be complicated by purulent coxitis, and wounds of the sacrum – by dysfunction of the pelvic organs and purulent meningitis. In some cases, after gunshot pelvic fractures, sepsis develops. Gunshot gas bone fractures with damage to internal organs. Injury is very severe. Bladder injuries are divided into extraperitoneal and intraperitoneal, isolated and combined with injury to other internal organs. When the wall of the bladder is covered with a peritoneum (intraperitoneal damage), urine enters the free abdominal cavity. Symptoms do not differ from those that occur with injuries of the hollow organs of the abdomen, especially since injuries of the bladder in most cases are combined with injuries of the intestine. Examination of the wounded reveals symptoms of peritoneal irritation and the presence of fluid in the abdominal cavity. The wounded cannot pee. When catheterizing with a soft catheter, a few drops of urine stained with blood are released. This confirms the diagnosis of a bladder injury. When the anterior wall of the extraperitoneal section of the bladder is wounded, urinary infiltration of the prebubble tissue occurs and urine infiltration spreads to both sides along the abdominal wall upward and parallel to the inguinal ligaments. Palpation is determined by pain and pastiness in the suprapubic and both inguinal areas. Urination is impaired. From the first days, the wounded fever. By timely surgical intervention, the progression of phlegmon and fiber necrosis can be prevented. When the lower parts of the bladder are injured near the neck, urinary infiltration extends to the perineum, scrotum root, and anus circumference. If the proximal urethra is injured, an enlarged bladder, bleeding from the urethra, and urinary perineal infiltration are determined. Rectal injuries are divided into intraperitoneal and extraperitoneal. Often they are observed in the wounded at the same time, and rectal wounds can be combined with damage to the bladder, urethra, pelvic fractures, and injuries of other parts of the intestine. They are complicated by shock. A reliable sign of rectal injury is the passage of feces through an external wound. Finger examination of the rectum (blood on the finger) is important for diagnosis. With intraperitoneal wounds, blood is rarely detected during a digital examination. Usually the wounded complain of pain in the rectum. With combinations of wounds of the bladder and rectum, desires to the bottom are frequent, while liquid feces with urine and an admixture of blood are allocated . It is also possible the secretion of feces and gases through the urethra. Intraperitoneal ruptures of the rectum are complicated by peritonitis. With extraperitoneal wounds, purulent or putrefactive processes develop in the pelvic tissue and muscles. Perhaps the development of anaerobic infections.

Femoral hernia

Femoral hernia is rare. More often it happens in older women and is due to the structural features of the pelvis and age-related tissue changes. It is formed above the inguinal ligament, exiting through the femoral canal more often inwards from the femoral vein, less often inwards from the vascular bundle and behind it. The contents of the hernial sac are intestinal loops, omentum, ovary, bladder (sliding hernia). Infringed more other hernias (55% of cases) in view of low density and ductility femoral canal walls (located behind the pubic bone and Cowper’s ligament front –inguinal ligament inside – zhimbfnatova ligament).

Femoral hernia clinic

Usually, due to the small size (2-3 cm in diameter) of the hernia, neither the doctor nor the patient pay attention to it. Only in case of infringement, when severe pain, vomiting and protrusion appear, are they diagnosed correctly. Infringement is often the first symptom of a hernia. A hernia is defined on the upper third of the thigh. It is necessary to differentiate a femoral hernia with lipoma, inguinal lymphadenitis, a leak in case of spinal tuberculosis, and tumor metastasis.

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Acute Infectious (Septic) Arthritis

Posted on April 17, 2020  in Pain

Acute infectious (septic) arthritis can be a manifestation of sepsis caused by bacteria, fungi or viruses, due to wound, postoperative, birth infection, criminal abortion, or if there is a focus in the internal organs. The disease-causing microorganism can almost always be isolated from intraarticular fluid, tissues and blood. Joint infection is often the result of hematogenous introduction of bacteria from a distant site of infection, less often direct infection penetrates into the joint with injuries, puncture wounds of the feet, acupuncture, repeated injections into the joint, etc.
The main causes of septic arthritis are staphylococcal, streptococcal, gonococcal infections, as well as gram-negative microorganisms (Escherichia coli, Proteus) and others. Acute infectious arthritis can occur against the background of furunculosis, tonsillitis, pneumonia, after cystoscopy, operations on the organs of the abdominal cavity and urogenital system etc. Diabetes mellitus, malignant neoplasms, RA and other diseases, chronic alcoholism predispose to the development of infectious arthritis.
Damage to the joint (in 80% of cases – monoarthritis) develops against the background of other symptoms of sepsis. The knee and hip joints are more often affected, less often – the shoulder, elbow, wrist, ankle.
Typically acute onset of arthritis, with sharp pains, fever, chills. The infected joint is sharply painful, reddened, hot and swollen, contains effusion, mobility and function are severely limited due to pain. In case of a hip joint infection, the pain can radiate to the front of the thigh or knee, and in the case of the sacroiliac joint infection, to the buttocks, lower back or the area of ​​the sciatic nerve. Multiple joint damage with septic arthritis is rare, patients with SLE receiving immunosuppressive drugs are more prone to it.

Arthritis caused by fungi and mycobacteria

Arthritis caused by fungi and mycobacteria , also usually monoarthritis, begins and proceeds more imperceptibly.
When examining synovial fluid, high cytosis (20-104 / ml) is detected with a predominance (up to 90%) of neutrophils. The liquid is cloudy, its viscosity is reduced, the mucin clot is friable. X-ray diffraction of the capsule and edema of the periarticular tissues are noted, epiphyseal osteoporosis, narrowing of the joint gap, subchondral erosion are detected very early, and with inadequate treatment, rapid destruction of the cartilage and bone.
The outcome of the disease may be secondary deforming osteoarthrosis or bone ankylosis of the joint.
The possibility of an infectious etiology of arthritis should be assumed in all cases of acute mono- and oligoarthritis. The diagnosis is confirmed by examining synovial fluid – viewing smears stained by Gram, isolating the culture of microorganisms.
With septic arthritis, antimicrobials are used and adequate joint cavity drainage is performed. The sooner treatment is started, the more likely it is to maintain joint function, therefore antibiotic therapy is started until the results of inoculation of synovial fluid are obtained. After identification of the pathogen, treatment may be revised if necessary. Antibiotics that easily penetrate the joint from the blood are administered parenterally. Intra-articular administration of antibiotics is not necessary and may cause irritation of the synovial membrane. For streptococcal and staphylococcal infections, penicillin is used at 250 000 units / kg per day, on average for adults 12–20 million units intravenously, distributing the dose for 4 administrations, or 60–100 mg / kg zeporin per day in 2–3 doses. Treatment is carried out for 3-6 weeks.
In gram-negative flora, a combination of aminoglycoside (e.g. gentamicin) with a broad-spectrum antibiotic (penicillin series, cephalosporin) is recommended.
Shown daily or every other day the drainage of the joint cavity, with aspiration of pus, which allows you to save articular cartilage. It is necessary to ensure rest of the limb to reduce pain and inflammation, sometimes it is immobilized with a tire. Passive exercises can be started a few days after the start of treatment, and active ones – after the inflammation subsides, the joint load is prohibited until the symptoms of active inflammation disappear completely.
The course of treatment is 1 – 1.5 months.
With insufficiently effective treatment, the disease takes a long course with the formation of persistent joint configuration and limitation of mobility.

Gonococcal arthritis

Gonococcal arthritis is one of the options for septic arthritis. It develops in patients with acute and chronic gonorrhea with hematogenous spread of infection from the genitourinary tract. It is more common in young women, which often has an asymptomatic course of the disease, as well as menstruation and pregnancy-contributing bacteremia. In the development of gonococcal arthritis, 2 phases are distinguished – a short (2–4 days) “bacteremic” characterized by fever, chills, migratory arthralgia, and a long “septic” lesion of one or two joints (usually knee, ankle, elbow, wrist). Inflammation of the calcaneal tendon, as well as damage to the ankle joints with the development of the so-called “flat gonorrheal foot” is considered characteristic of gonococcal infection. The latter is associated with the spread of infection from the ankle joint to the metatarsal and tarsal joints, with simultaneous atrophy of the muscles of the foot and lower leg and the development of flat feet. The outcome of gonococcal arthritis, as a rule, is secondary deforming osteoarthrosis. The diagnosis of the disease is confirmed by positive blood culture, the detection of gonococcus in the synovial fluid or specific skin manifestations of the infection – papules on a red base, usually filled with purulent contents with necrosis in the center and localized on the back, distal extremities or around the joints. Differential diagnosis of gonococcal arthritis should primarily be carried out with arthritis in Reiter’s syndrome. With gonococcal arthritis, massive doses of antibiotics are effective. You can use the following combination of drugs: penicillin intravenously at 10 million units per day to reduce the clinical manifestations of arthritis, then ampicillin 2.0 g for 7-10 days or high doses of penicillin intravenously or intramuscularly for 3 days, then ampicillin 3.5 g day for 7 days. Recommended repeated daily aspiration of synovial fluid and the appointment of non-steroidal anti-inflammatory drugs. Osteoarticular tuberculosis is one of the frequent extrapulmonary forms of tuberculosis. There are tuberculous arthritis, spinal tuberculosis (Pott’s disease) and Ponce arthritis.

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Tuberculous arthritis

Posted on April 13, 2020  in Pain

Tuberculous arthritis is a chronic destructive form of septic arthritis caused by mycobacterium tuberculosis. It is more common in men over the age of 50-60. The combination of joint and lung damage is optional. The development of tuberculous arthritis is more often associated with the hematogenous spread of infection, the formation of the primary bone focus (osteitis) and the transition of a specific inflammatory process to the joint. The primary synovial form of tuberculous arthritis is much less common. As a rule, a large joint is affected – the knee, hip, ankle, and wrist. The affected joint is edematous, warm to the touch, moderately painful, movements in it are limited. In a number of patients, joint function is limited due to pain and reflex muscle contractures. Muscular atrophy may develop. When the wrist joint is affected, “carpal tunnel syndrome” often develops, which is clinically manifested by an infringement of the median nerve. Often, periarticular tissues are involved in the pathological process with the development of a “cold abscess”, that is, an abscess without pronounced erythema and tenderness on palpation. In the synovial fluid, the number of leukocytes (mainly neutrophils) exceeds 10,000, in about 20% of patients mycobacterium tuberculosis is sown from the synovial fluid. X-ray in the early stage of arthritis reveals diffuse osteoporosis, marginal bone defects, rarely a limited bone cavity with sequestration. In the late stage of arthritis, destruction of the articular ends of the bones, their displacement and subluxations often occur. For the diagnosis, seeding of a specific culture from the joint cavity, biopsy of the synovial membrane with the identification of characteristic tuberculous granulomas during its histological study, the detection of other tuberculous lesions in the body, positive reactions to tuberculin during skin tests (Pirke, Mantoux reactions) are important. Spinal tuberculosis (Pott disease) occurs mainly in children and young people (up to 30 years). In adults, the lower thoracic and upper lumbar are more often affected, in children – the thoracic spine. Specific bone changes are localized along the edges of the vertebral bodies, and one or two adjacent vertebrae are affected. As a rule, lysis and sclerosis of the bone with destruction of the articular cartilage are noted, as indicated by a narrowing of the joint space. As the destruction of the bones, the front of the adjacent vertebrae contracts, contributing to the formation of a hump. The process often goes to the intervertebral cartilage, paravertebral tissue, which is accompanied by the formation of paraspinal cold abscesses. Abscesses can spread along the spine or rib and reach the chest or sternum. When involved in the pathological process of the cranial nerves, severe neurological symptoms are often detected, up to paraplegia. Damage to the lumbar spine is observed less frequently and is clinically manifested, as a rule, by unilateral sacroileitis. For the diagnosis of spinal tuberculosis, X-ray examination and computed tomography are important. Also in the diagnosis of tuberculous arthritis, the final diagnosis is based on data from a bacteriological study of the contents of a cold abscess. Differential diagnosis is carried out with lesions of the spine in other infections, tumor metastases in the spine. Ponce polyarthritis is reactive arthritis that develops against the background of visceral tuberculosis. The defeat of small joints is characteristic. Clinically noted constant long-term pain in the joints and their swelling. Suppuration of joints and the formation of fistulas in them does not happen. There is a strict parallelism between the severity of the main process and the clinical manifestations of joint damage. With the subsidence of visceral tuberculosis, changes in the joints completely disappear. Differential diagnosis is carried out with RA. For tuberculosis of the osteoarticular system, as well as tuberculosis of the visceral organs, a long-term (usually at least 2 years) treatment is carried out with two bactericidal drugs, for example, isoniazid (tubazide) in combination with streptomycin, PASK or rifampicin or other anti-tuberculosis drugs. In addition, special orthopedic treatment methods must be widely used.

Brucellosis Arthritis

Brucellosis arthritis is relatively rare. It develops against the background of other clinical manifestations of brucellosis – wave-like fever with chills and heavy sweats, swollen lymph nodes, liver, spleen, changes in the nervous system, more often in chronic forms. It occurs in persons who have contact with animals suffering from brucellosis, or when using products from such animals. In acute brucellosis, arthralgia and myalgia are short-lived, quickly disappear with the appointment of antimicrobial therapy, and can pass on their own. Most often, brucellosis develops spondylitis and sacroiliitis, especially in the elderly with a severe course of the disease. Sacroileitis develops in the 1st month of the disease. It can be one-sided or two-sided. The lumbar spine is usually affected. Often an intervertebral disc is involved in the process, which is manifested by a narrowing of the intervertebral fissures; destruction of the vertebral bodies and calcification of the longitudinal ligaments at the level of the affected discs are observed (ossifying ligamentitis). Vertebral osteoporosis, periosteal thickenings, paravertebral abscesses can be detected. Damage to the intervertebral joints is not characteristic. The diagnosis is complicated. To establish it, an epidemiological history, specific tests for brucellosis – a Wright test in a titer of more than 1: 200, a skin test with brucellosis antigen (a positive Burnet reaction ) are necessary. Differential diagnosis is carried out with ankylosing spondylitis, tuberculous spondylitis, osteomyelitis. The most effective combined use of antibiotics: tetracycline 500 mg 4 times a day for 6 weeks and streptomycin 1 g intramuscularly per day for 2 weeks.

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Lyme disease

Posted on April 9, 2020  in Pain

Lyme disease , or systemic tick-borne borreliosis, is an infectious disease that affects mainly the skin, nervous system, heart and joints. It is known relatively recently, it was isolated in an independent nosological form only in 1977. The name of the disease comes from the name of the village of Lyme in Connecticut (USA), where the epidemic of this infection was first recorded. It has now been proven that the disease is spread not only in the United States, but everywhere. Epidemics in Europe, Australia; Asia, China, Japan. The disease is caused by one of the varieties of spirochetes – Borrelia burgdorferi, ixodid ticks are the carrier. The peak incidence occurs in the summer months, mainly children and young people are sick.

The main clinical sign is erythema migrans, usually on the hips, in the inguinal and axillary regions. Fever, chills, headache, myalgia, lymphadenopathy, splenomegaly are observed. Sometimes neurological disorders are detected – neuritis, especially with damage to the cranial nerves, paresis of the facial nerves is often observed. In severe cases, the clinical picture of serous meningitis, encephalitis is noted. Damage to the heart develops in 4-8% of patients, the most common is atrial ventricular conduction, up to the development of complete transverse blockade. Myocarditis with left ventricular failure, pancreatitis can be observed. Joint damage develops in 60% of patients within a few months to 2 years from the onset of the disease. Usually, one or several large joints (knee, elbow, shoulder, etc.) are affected, and symmetric polyarthritis is often found. Arthritis resolves on its own within 1-2 weeks, but can recur for a number of years. Some patients develop chronic arthritis with erosion of cartilage and bones, joint ankylosis is extremely rare. The diagnosis is made in the presence of a characteristic skin lesion – tick-borne erythema. It is necessary to take into account the epidemiological factor: the disease occurs in areas where there are carriers – ixodid ticks. The presence of typical clinical manifestations of the disease – neurological, cardiac and articular lesions – allows you to confirm the diagnosis. If cutaneous erythema is absent, the diagnosis should be based on the results of a serological examination. Abroad, a sensitive and highly specific enzyme immunosorbent method (ELISA) is used to confirm the diagnosis. Differential diagnosis at the first stage of the disease during erythema is carried out with skin lesions of a different nature, with complications from the nervous system – primarily tick-borne encephalitis, which is also transmitted by ticks and is found in central Russia. In the early stages of the disease, tetracycline 250 mg 4 times a day, penicillin, erythromycin are effective. Arthritis is treated with vibramitia (doxycycline hydrochloride) 100 mg 2 times a day, penicillin 20 million units (fractionally) per day for 14 days.

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Viral arthritis

Posted on April 5, 2020  in Pain

Viral arthritis is found in acute viral hepatitis, rubella, mumps, smallpox, arbovirus infection, infectious mononucleosis, etc. Arthritis rarely develops with influenza, arthralgia and myalgia associated with general intoxication are more common. The pathogenesis of joint damage during viral infections can be associated with the deposition of immune complexes containing the antigen, and with the direct effect of the virus on the synovial membranes. The characteristic signs of viral arthritis are the short duration of joint damage and usually the complete reversibility of the process. In acute viral hepatitis, arthralgia often develops, less often – migrating arthritis. Both small and large joints are involved in the process. Arthralgia or arthritis can appear in the prodromal period, disappearing in the midst of jaundice. Arthritis can be combined with hives and headaches. Sometimes the joint syndrome persists for several months, simulating a picture of RA. Cases of development of classical RA in patients with viral hepatitis are also described. With rubella, arthritis is often observed, mainly in women, as well as in children and adults after vaccination with a live vaccine. Symptoms of arthritis can be detected at the same time as the rash appears, or appear a little later. The most characteristic lesion of the small joints of the hands. The duration of arthritis is on average up to 2-3 weeks. Residual effects are usually absent, although the role of rubella virus in the development of RA is not ruled out. With mumps, arthritis is rare (in 0.5% of patients), more often in people over 20 years of age. It manifests itself on the 8-21st day from the onset of the disease, in some patients simultaneously with the development of mumps or even before the onset of swelling of the parotid glands. Typically, joints are affected in patients with bilateral lesions of the parotid glands, often along with other complications (orchitis, pancreatitis). The appearance of arthritis is accompanied by a new wave of increase in telag temperature. Swelling of the joints develops, movements become painful. The most characteristic lesion of large joints, but small joints of the hands and feet may be involved in the process. The duration of arthritis is from two to several months. It ends with a full recovery. Paraneoplastic arthropathies . Nonspecific osteoarticular changes observed in malignant tumors of various localization, within the framework of the paraneoplastic syndrome, can long precede the appearance of other symptoms of the tumor (“joint masks” of the tumors), develop simultaneously with them or later. The clinical manifestations of the disease are diverse. The most common are Marie-Bamberger syndrome (hypertrophic osteopathy), amyloid, dysmetabolic (gouty) arthropathy, nonspecific mono-, polyarthritis, arthralgia, tendovaginitis, myalgia.

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WAR ON DRUGS

Posted on April 1, 2020  in Painkillers and other drug

Right now the time has come to hear, take into account and try to clarify the opinion on these issues. For some time there were general attacks on the Bill of Rights under the pretext of the so-called drug war. For some reason, the problem of psychoactive substances has become even more frightening, more insidious for society than communism at one time. The quality of the rhetoric coming from the psychedelic community should be radically improved. If this is not done, we will lose the opportunity to use our birthright, and all the possibility of studying the psychedelic dimension will be closed. Ironically, this tragedy can occur as a kind of footnote to the prohibition of synthetic and addictive drugs. It will never be superfluous to say that the issue of psychedelics is a matter of civil rights and civil liberties. This is a question related to the most important of human freedoms — the freedom of religious practice and the private expression of the individual mind.

It was once said that women should not be given the right to vote, otherwise society will perish. And before that, kings could not give up their absolute power: otherwise there would be chaos. And now we are told that it is impossible to legalize psychoactive substances, since otherwise the collapse of society will occur. This is absolute nonsense. As we have seen, human history can be described as a series of relationships with plants, relationships established and broken. We explored many of the ways in which plants, substances, and politics were violently confronted, from the effects of sugar on commerce to the effects of coffee on a modern employee, from the British opiate pressure on the Chinese people to the use of heroin in the ghetto by the CIA to create disagreement and discontent.

Our story is a story of relationships with plants. Her lessons can be made conscious, introduced into social policy and used to create a more prosperous, meaningful world, or they can be rejected, as happened with human sexuality, the discussion of which was forbidden until the work of Freud and others brought it to universal review. This analogy is appropriate, since the enhancement of the ability of cognitive experience, possible due to plant hallucinogens, is basically as fundamental to the essence of a person as sexuality. The question of how soon we will develop into a mature community capable of addressing these topics depends entirely on us.

HYPERSPACE AND HUMAN FREEDOM

What is most afraid of those who advocate for a non-working Luddite decision such as “just say no ” is a world in which all traditional social values ​​dissolve in an encounter with individuals and populations obsessed with psychoactive substances and an endless search for self-satisfaction. We should not rule out this too real possibility. But one should reject the idea that such a disturbing, by all accounts, future can be avoided by witch-hunts, the prohibition of research and the hysterical spread of misinformation and lies.

Since time immemorial, psychoactive substances have been part of the galaxy of culture. And only with the advent of technologies capable of purifying and concentrating the active components of plants and herbal preparations, these substances are separated from the general tissue of cultural affairs and instead become a kind of scourge.

In a sense, our problem is not the problem of psychoactive substances, but the problem of controlling our technology. Are we expecting in the future the emergence of new synthetic substances, a hundred, or even a thousand times more capable of causing addiction than heroin or crack? The answer will be an absolute “yes” if we do not recognize and investigate the inherent need for chemical dependence in humans, and then we do not find and approve any ways of expressing this need. We discover that human beings are creations of a chemical habit, with the same terrible distrust with which the Victorians discovered that humans are creations of sexual fantasy and obsession. This process of meeting with oneself as a species is a necessary precondition for creating a more humane social and natural order. It is important to remember that the adventure of such a meeting with oneself does not begin with Freud and Jung and does not end with them. The argument, carefully developed in this book, is that the next step in understanding ourselves can only occur when we take into account our innate and legitimate need to live in an atmosphere rich in mental states that are caused by our own free will. I am confident that we can begin this process by reviewing the sources of our origin. Indeed, I made great efforts to show that in the Archaic environment, in which self-reflection first appeared, we find the keys to the origins of our troubled history.

WHAT’S NEW

Hallucinogenic indoles, unexplored and prohibited by law, are presented here as agents of evolutionary change. These are biochemical agents, whose final effect is not on the direct experience of the individual, but on the genetic constitution of the species. In the first chapters, attention was paid to the fact that increasing visual acuity, improving the ability to reproduce and enhancing the stimulation of the protolinguistic functions of the brain are the logical consequences of the inclusion of psilocybin in the food of an ancient person. If one could prove the idea of ​​the emergence of human consciousness in connection with the indole-mediated synergy of neurodevelopment, then our image of ourselves, our attitude to nature, and the current dilemma regarding the consumption of psychoactive substances in society would change.

We cannot solve the “drug problem”, nor the problem of environmental destruction, nor the problem of stockpiles of nuclear weapons, until our image of ourselves as a species is again connected with the Earth. This business, first of all, begins with the analysis of a unique combination of conditions that are necessary for the organization of the animal in order to make a leap towards conscious self-reflection. When the main meaning of the “man-plant” symbiosis mediated by hallucinogens is understood in the scenario of our sources, we are able to understand our current state of neurosis. The lessons learned from those long-standing and formative events can lay the foundation for decision-making not only regarding the need to manage the consumption and abuse of substances in society, but also about our deep and growing need for the spiritual dimension of life.

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MEETINGS WITH WONDERFUL OVERPRISE

Posted on March 27, 2020  in Painkillers and other drug

The softening of Western rationalism has gone very far, which anyone can easily be convinced by reading some modern popular book on cosmology or quantum physics. Nevertheless, I would like to throw a little more heat through introducing the idea of ​​some connection between the measurements, which is achieved most reliably and directly by using indole hallucinogens with their long history of human consumption and their evolution together. Such compounds, obviously, act as regulators of cultural change and can be a means of gaining access to the intent of some very large self-regulating system. Perhaps this is the Superintelligence of our whole species or some kind of “planetary mind”, or maybe we were too limited in our search for an inhuman mind, and some completely different, radically different from us, intelligent species shares our stay with us The earth.

I offer these ideas in a speculative way. I do not have solid personal knowledge of what is happening here. I just believe that I have a sufficient understanding of the customs, expectations, criteria of evidence and the “general knowledge” of human beings to be able to note that what happens when DMT is drunk is much more peculiar than anything that could be termed “intoxication”. Under the influence of DMT, the mind finds itself in a convincingly real, clearly alien world that coexists with us. Not in the world concerning our thoughts, hopes, fears, but rather in the world of babies – their joys, dreams, their poetry. Why? I have not the foggiest idea. These are just facts: this is how it happens to us.

Among the main schools of thought of the 20th century, only Jung’s psychology sought to consider some of the phenomena that are so important for shamanism. Alchemy, which Jung studied very carefully, was the heiress of a long tradition of shamanistic and magical methods, as well as more practical chemical procedures – such as metal processing and embalming. Literature on alchemy testifies that the uplifting swirl of the contents of an alchemical vessel was fertile soil for projecting the contents of a naive pre-scientific mind. Jung insisted that alchemical allegories and emblems were the product of the unconscious and could be analyzed in exactly the same way as dreams. From Jung’s point of view, the discovery of the same motives in the fantastic speculations of the alchemists and in the dreams of his patients was a serious support for his theory of the collective unconscious and universal common archetypes of the latter.

In his study of alchemy, Jung came across reports of Kabiri – elven alchemical children whose appearance or tangible presence is an integral part of the last stages of alchemical creation. These alchemical children are like those little helper spirits whom the shaman calls for help. Jung regarded them as some autonomous side of the psyche that temporarily got out of the control of the ego. Unfortunately, the explanation that these alchemical geniuses are “autonomous aspects of the psyche” is not an explanation at all. This is the same as describing an elf as a small non-physical entity of indeterminate origin. Such explanations only postpone the need for contact with the deeper nature of the experience itself.

Science was not useful in the matter of elusive human contacts with other types of mind. She prefers to direct her attention somewhere else, noting that subjective perceptions, although unusual, are not her area. What a pity, since subjective experience is all that any of us have. In any case, to a large extent the subjective nature of the so-called objective universe is now confirmed by the most objective of the sciences – physics. In new physics, the subjective observer is inextricably linked with the observed phenomena. Interestingly, but this is a return to the shamanistic point of view. The true intellectual legacy of quantum physics may be the new respect and priority that it places on subjectivity. Turning us to subjectivity also means endowing the language with a tremendous new force, since language is the material from which the subjective world is made.

Thanks to psychedelics, we learn that God is not some kind of idea, God is a lost continent in the mind of man. This continent was rediscovered during a great danger to us and our world. What is it? Coincidence, synchronism, or a brutally senseless neighborhood of hope and death? Several years ago, I turned the work of my life to understanding the mystery of the experience caused by tryptamine hallucinogens. After all, this mystery is not one that can be explained by science. Of course, I understand that people distribute their obsessions, trying to fill the whole space. But in the critical events surrounding the emergence of cattle breeding and language in human beings, I found an ancient echo of those moments that I felt and witnessed personally.

Today it is necessary to face the sought and found answer. Before us is a flickering dimension, so enormous that its contours can hardly be accommodated in the focus of the human coordinate system. Our animal existence, our planetary existence ends. According to geological time, this end is only in a few moments. The great dying, the great extinction of many species has occurred at least since the climax of the pinnacle of partner society in prehistoric Africa. Our future is in the mind; the only hope for the survival of our weary planet is that we will find ourselves in our minds and make of it a friend who can reunite us with the Earth, while taking us to the stars. A change, more radical in significance than all that was before, looms directly ahead. Shamans have kept the gnosis of the availability of the Other for millennia; today is planetary knowledge. The consequences of this situation have only just begun to emerge.

Naturally, I do not expect my words to be taken seriously. However, these conclusions are based on experience that is accessible to anyone who finds the time to investigate DMT. The experience itself lasts less than fifteen minutes. I do not foresee criticism from people who did not bother to conduct this simple and unconditional experiment. After all, how seriously can critics deal with the problem if they are not disposed to take a few minutes of their time to experience this phenomenon on their own?

Deep psychedelic experience not only offers the opportunity to live in a world of sane people, in harmony with the Earth and with each other. He also promises an excellent adventure, a meeting with something completely unexpected – with some other neighboring world, full of life and beauty. Do not ask where he is; at the moment we can only say – not here, not there. We are still obligated to acknowledge our own ignorance regarding the nature of the mind and regarding exactly what the world is to be and what it is. For several millennia, and even more, our dream was to understand these issues, and we were defeated. Yes, defeat, if we do not remember another possibility – the possibility of “completely different.”

Some lost souls scan the heavens in search of a friendly “flying saucer” that will penetrate the earthly sphere and take us to Paradise; others suggest seeking salvation at the feet of various rishis, roshis, geishas and gurus. Researchers would better look into the work of nerds, anthropologists, and chemists who located, identified, and characterized the hallucinogens of shamans. Thanks to them, we got our hands on a tool for the salvation of human souls. This is a great tool, but it is a tool that should be used. All our addictions for centuries – from sugar to cocaine and television – have been a tireless search for something taken from us in Paradise. The answer has been found. There is nothing more to look for. He is found.

RETURN TO OUR SOURCES

Using plants of the type described above will help us understand the valuable gift of partnership with plants, lost at the dawn of time. Many people crave facts about their true identity. Plant hallucinogens clearly direct this essential identity. Not knowing your true identity means being some kind of crazy, soulless thing, a golem. And, of course, this image, painfully Orwellian, is applicable to the mass of human beings now living in societies of highly developed industrial democracy. Their authenticity lies in their ability to obey and follow the changes in the mass style that are conveyed by the media. Preoccupied with the consumption of anesthetized food, the absurd communications of the media, and the politics of disguised fascism, they are doomed to a poisoned life at a low level of consciousness. Possessed by the daily television program, they are the living dead, lost for everything except the act of consumption.

I believe that the failure of our civilization to resolve issues related to the problem of psychoactive substances and habitual destructive behavior is an unfortunate legacy for all of us. But if we sufficiently rebuilt the image of ourselves and the image of the world, we could make a tool from pharmacology that gives us the most ambitious hopes and dreams. Instead, pharmacology has become a fiendish servant of the rampant slide into regulation and the destruction of civil liberties.

Most people have a predilection for certain substances and, more importantly, everyone has a predilection for one or another standard of behavior. Trying to see the difference between habits and addictions threatens the indissoluble fusion of mental and physical energies that form the behavior of each of us. People who are not involved in relationships of food stimulation or stimulation with psychoactive substances are rare, and judging by their commitment to dogma and the intentional narrowing of their horizons, they were not able to create any viable alternative to involvement in substances.

Here I tried to explore our biological history and our more modern cultural history in search of something that might be missed. My theme was human agreements with plants, created and torn over the course of millennia. These relationships formed every aspect of our identity as self-reflecting creatures – our language, our cultural values, our sexual behavior, what we remember and forget in our past. Plants are a lost link in the search for an understanding of the human mind and its place in nature.

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DIFFERENT RELATIONSHIP TO SPEECH

Posted on March 23, 2020  in Painkillers and other drug

This “scientific” position in the 19th century was typical for educated consumers of opium and hashish. Usually, researchers turned to these substances in order to “ignite the creative imagination” or for the sake of vaguely defined “inspiration”. Similar motifs were behind the use of marijuana by beat writers, as well as jazz artists before them, and rock performers after them. Some myths of the underground culture are scornful of the popular belief that cannabis could make some kind of contribution to the creative lifestyle. And nevertheless, a certain part of the cannabis-consuming community continues to use it for this very purpose.

The pharmacological profile of a psychoactive substance determines only some of its parameters; the context of its consumption (or, according to the successful expression of Leary and Metzner, “furnishing”) is no less important. The context “recreational”, as it is understood today in the United States, is an atmosphere that lands the cognitive effect of the substance being consumed. Small doses of most psychoactive substances affecting the central nervous system are perceived by the body as artificial stimulation or as energy that can be directed outward in the form of physical activity in order to somehow express this energy and extinguish it. This pharmacological fact lies behind most of the “recreational” insanity against psychoactive substances – legal or illegal. Wednesday, teeming with social cues,supersaturated with noises and distracting visual impressions (a nightclub, for example) is a typical culturally-embraced context of consumption of means for relaxing.

In our culture, private consumption of psychoactive substances is considered as something dubious; their solitary consumption looks like something unhealthy, and in fact all introspection is also considered. The archaic model of consumption of psychoactive plants, including cannabis, is quite the opposite. Ritual, solitude and disconnection of the senses are the methods used by the shaman of Archaic, who intends to go on a journey through the world of spirits and ancestors. Undoubtedly, hemp is “used up” in terms of consumer product and understated, defining it as a means for “relaxing”, but it is also certain that consumed periodically in the context of ritual and cultured expectations that this experience will transform consciousness, cannabis is capable of almost the full range psychedelic effects associated with hallucinogens.

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