4 курс / Дерматовенерология / Dermatologia_i_venerologia_KGMU_g_Simferopol_2012_g

ileiteH.ue. Bee MeTO,llbI Ae'ieHHHIIKP HanpaBAeHbI Ha. pa,llHKaAhHoe Y,llaAeHHe onyxoAH H n0Ayqett11e CTOHKOf'OKAHHH'leCKOf'OH3Ae'ieHH5! . Bb16op MeTO,lla Ae'-eHH!.SI 3aBHCHT OT AOKaAH3aU.HH, CTa,llHH, p a cnpocTpaHeHI·rn npou.ecca, HaAH'lH.SIMeTaCTa30B, B03pacTa H o6ru.e- ro cocTOHHH.SI 60AhHOro. Ha1160Aee qacT o rrpH Ae'leH H IIKP HCilOAh3YJOTCH XHpyprw-IeCKHe MeTO,ll,hI HCCe'-leHHHorryxOAH B rrpeJ(eAax 3,ll,0- pOBbIX TKaHeii, OTCTyria.51 Ha 1,5-2 CM OT KpaH o6pa30BaHH5!, c IlOCAe-

.uymm:eii IlA8.CTHKOH KO:>KH, 3AeKTpo- H KpHOJ(eCTPYKU.H.SI, KIOp eTa.>K,

K OTOpbie npHMeHSIIOTC.H rrpH He60AblJ.IOM (11:0 2 CM) Al-18.MeTpe onyxoAH, c ofol3aTeAbHbIM 3axBaT OM 6 MM rrpm1er a.rou.1,ei1: K orryXOJ\H 30HhI 3,ll,0- poBOM KO:>KH . /\.yqeBaH T eparrH5! noKa3aHa npH peU.HJJ..HBHOM Te'lemm

B03paCTa. IIpH pacnpoCTpaHeHHH npou.ecca HCilOJ\b3YeTC5! CHCTeMHaH XHMHOT epanH 5!. TaJOKe HCilOJ\h3YIOT rrpe n a paTbI HHTepcpepoHa (B BH,n:e BHYTPHO'-!arosbrx o6KaAhIBaHHH), apoMaTH'!ecKHepeTHHOHJ(bI.

llpo</Jtutax:muica. )J.AJr rrpe.uynpe>K,D;eHH.SI pa3BHTHH IIKP BIDKHO CBOeBpeMeHHOe J\e'leHHerrpe,n,paKOBbIX .n:epMaT030B. BOAbIIIOe

3Haqe1-rn:e .HMeeT 38.IIl,HTa KOJKH OT Y<P-Ayqeil. COAHU.a, 803,n:e:ikTBIDI

KaHu.eporeHHbI X cpaKTOpOB, oco6eHHO OT HOHH3Hpy1oru.ero 06AyqeHIDI.

MeTaTHDH'<ICCKHHpaK Ko:ac11 (MTJ!>) ·- 3IIHTCAHaAbHasr orryXOAh, 38.HHMaIOIIl,8.5! rrpoMe:a..'y-TO'IHOe(•MeTa•) IlOAO:>KeHHe Me>K,D;Y 6a-

38.AbHO-KAeTO'IH.bIM (BKP) H IlJ\OCKOKAeTO'IHbIM (IIKP) paKOM KO:>KH . '1:acToTa MTP coCTaBMieT ,n,o 2 % Bcex onyxoAeli KO:lKH. Cpe,n,H 6a3aAHOM oHa 3aHHMaeT OT 5 ,n,o 15 %. MTP '-laUiepa3BHBaeTc5! B no:ikHAOM B03 pacTe: OT 60 ,n,o 80 AeT. KaK H 6a3MHOMa, MTP '-laII.1,eAOKMH- 3yeTC5! Ha AHU.e, oco6eHHO B o6AaCTl1 HOCa H ynIHbIX paKOBHH, HeCKO/\bKO pe:>Ke - B o6AaCTH BHCKOB, A6a, BOAOCP.CTOH '-!aCTHf'OAOBbI, weH, B03 MO.>J<..l:-Ia /\0KaAH38.U.H51 Ha IWJ>Ke CilH HbI H KOHe'iHOCTeil:. OnyXOAb MO:>KeT pa3BHBaThC5! H a HeH3MeHeHHOH KO:iKe, T. e. MO)KeT 6b!Tb rrepBH'iHOHHAM B03HHKaTb KaK p eU.H,llHB cym,eCTBYIOW.eH 6a3aAHOMbl,

nocJ\e ee Ae'ieHH.SI. MTP OTJ\H'-!aeTc.H 6oAbUieH: arpeccHBHOCThIO, 'ieM

6a3MHOMa, HO MeHbweil:, 'leMITJ\OCKOKAeTo'iH.bIHpaK. MeTaTHITH'-Ie- CKHH paK KO:lKH MeTaCTa3HpyeT B 8 % CAyqaeB, 6a3aAHOMa - B 0, 1 %.

KnuH.uica. KaK npasHAo , oqar MTP O,llHHO'iHbI:il:, o 6bI'-IHO rrpe,n,cTaBMieT co6oii .H3BeHHbIH onyxo AeBbIH o'iarpa3MepoM 1-3 CM B )'.J,HaMeTpe: 9.3 BeHHbIH ,llecj:JeKT qaw.e HerrpaBHAhHOH cpopMbI, c HepoB- H b IMH o6pb1BHCTb lMH MAH IlOl.l,pbITbIMH Kpa5!MH . ,[lHO .H3BbI 'iaT n - Kpb!TO TeMHO-KOpH'iHeBOHrpy6o:H KOpKOH, KOTOpaH J\enco OTI'J l.'U

CH rrpH H e 60J\blliOH TpaBMaTH3aQHH H KpOBOTO"-IHT. Kp

281

-raMH HMeIOT Ba.uiKOo6pa3HbIH xapa.xTep. BecbMa xapaKTepHa J1.IU'I

3TOI'OrropaJKeHID1 30Ha n1rrepeMHH (OKOJ\O 5 MM) BOKpyr OII)'XOJ\eBoro O'lara. IlpH Ilal\bITaIJ,HH OII)'XOJ\bIlJ\OTHrul, cy6'beKTHBHO601\bHOro 6ecIlOKOHT HOIOUJ:He IlOKal\bIBaHHSl, KpOBOTO'lHBOCTbH 3y,ZI..

Ae<teHue. IlpH J\e'leHHHMeTaTHnH'!ecKoropa.Ka KO:lKH B Ha-

cTo Hrn:ee BpeMH HCilOJ\b3yeTCH npocnH,ZI.HH (0,05-0, 1 r e:>Ke,ZI.HeBHO BHyTpHMbil.lle'lHO, Ha Kypc 3,5 r) B KOMfornaIJ,HH c 61\H3Ko¢oeycHOH peHTreHOTepanHeH B JJ:03e 500 p c pHTMOM 061\)"leHllil 5 cppaKI.l;HH B He,n:eAIO. T aIOKe rrpHMeHHIOTC5l IIO IIOKa3aHHSIM XHpyprH'leCKOeAe'leHHe H .n:pyrHe MeTOJJ:bl, HCil0Ab3)'eMbie Jllill Ae'leHHH 6a3al\bHO-

KJ\eTO'lHOrop aKa. B nocAe,ZI.HHe ro,n;hI JI/ill Ae'1eHHHMTP HCIIOAh3yeTcH cpOTOAHHaMH'leCKaHTepanHH.

II. MeAaHOMa KOlKll

MeJ\aHOMa KO:lKH COCTaBAfieT 2-3 % 31\0Ka'leCTBeHHbIXorryxoAeH. 3a6oAeBaeMOCTb MeAaHOMOH pacTeT, H ee IlOKa3aTeAH Ka)K,L(bi e

10-15 AeT BO MHOrHX crpaHax MHpa y.n;BaHBalOTCH. MeAaHOMa SIBMIeTCSI O)l;HOH H3 HaH6oAee 31\0Ka'leCTBeHHbIXonyxoAeH c O'leHharpecCHBHbIM, nopo:H: Henpe,ZI.CKa3yeMbIM Te'leHHeM, 6ypHbIM AHMcporeH- H bIM H reMaToreHHblM MeTaCTa3HpOBaHHeM, BbI COKOH CMepTHOCTblO. MeJ\aHOMa pa3BHsaeTCH H3 nHrMeHT006pa3y1orn:Hx KJ\eTOK - MeAaI-IO- UHTOB, a IT03TOMY B 75 ,7-87,1 % CJ\Y'laeBrropruKaeT KO:Hcy, B OCTal\b- HbIX CA)"laHX o6Hapy:lKHBaeTCSI B ;:i;pyrux opraHax.

MeJ\aHOMa pa3BHBaeTc sr H3 rrpe;:i;lllecTsyrom.ero apo:lK;:i;eHHOro HAH rrpH06pe-re 1-1Horo IIJirMeHTHOro Hesyca B 20--85 % scex CA)"laeB, pe:lKe -- Ha OCHOBe rrpeKaHI.i;ep03HOro MeAaH03a ,[{ro6peH, HHOr,n:a MO- )i{eT ITOSIBHTbC5l Ha HeH3MeHHOH KO:lKe (me lanoma de novo) . YcAOBHO pa3AH'-laJOTHeByChl «Me A aHOMOOIIaCHbJe• (nHrMeHTHbIH norpaHH'lHblH Hesyc, HeByc 0Ta, niraHTCKHH IlHTMeHTHbIH BOAOCSIHOH HeByc, orpaHH'leHHbIHMeAaH03 ,[{ro6peg) H HeByCbl « MeA aHOMOHeonaCHbie» (m-i:yT- pH,n:epMal\bHbIH ITJi!rMeHTHbIH nesyc, cpH6po3IIHTeAHaAbHbIH Hesyc, rrarrHAAOMaT03HhIH H BeppyK03HhIH Hesychr, halo-Hesyc, neByc CeT - TOHa H HeKOTOpbre ,n:pyrHe 6011.ee pe,n:Ko BCTpe'lalOIJJ;HeCSInHrMeHTHbie H nHrMeHTHpOBaHHhie HeBOH.ZI.Hbie o6pa30BaHllil.).

4>aicmop&t pucica Me.naNOM&t:

•retteTWieCKHe Mapicepb1 (MYTaQl1SI reH:a CDKN2A),

•cseTO'IJBCTBwrenhHOCTbKO:nn1 I H II nma,

•AMCIInaCTI1'-leCKl1eHesycbl Mn11 MeJiaHOMa B ceMei1HOM aHaMHeJe,

•MenaHOMa B aHaMHe3e,

282

,,ao3gel1crn11e Y1ThTPa¢11oneToaoro HJny'IeHW51,oco6eHHO corrtte'IHbie O)KOTM, nony'IeHHbleB .a;eTCTBe, M nepKO.[.\M'IeCKOeMHreHCMBHoe 06rry'IeH111ecoJIHQeM HeJaropenol1 KO:>Kl1,

•KOJil1'IeCTBO(>50) H pa3Mepbl (>5 MM) rrpno6pereHHbIX HE'BOKJleTO"I- HbIX Heaycoa,

•apo)J(,[J,eHHbie tteaoKJieToqHbre tteaycbI,

•KOJillI"IeCTBO .[.\llICnJiaCTWieCKMX Heaycoa (>5),

•CHH,a;pOM .L\HCITJJaCTM'IeCKY!XHeaycoa.

KltuHuKa. MMHH'IecKHe rrpo5IBAernrn MaJ\Ji£rHH3aIJ.HH nHrMeHTHoro ttesyca, H3 KoToporo 'iaIQeacero pa3BHBaeTC51 MeAaHoMa, sechMa pa3Hoo6pa3HhI. CHa'iMa3TO MOIJ'T 6hITh 3y,n: H :>iOKei-me a o 6AaCTH •POAHHKH•, yseAH'ieHHeee pa3MepoB HAH n05IBl\.eHHe 6hICTpopaCTYIQero y3eJ\Ka (y3Aa) a u.eHTpe HAH no nepmpepHH Hesyca. 3TH 5IBl\.eHH51, KaK npaBHAO, corrpOBOJK,n:aroTC5I rHnepeMHeH H OTeKOM KO-

JKH a oqare nopa:>KeHH51 c HHcpHAbTpau;Heli 110,l(Ae)KaIQHX TKaHeli . He- p e,n:Ko Hesyc H3'b513BJ\5IeTC51 Hl\.H KpOBOTO'iHT. Ero u;aeT MO:lKeT MeHHTbCH B pe3yAbTaTe n05IBAeHH51 TeMHblX BKpaTIAeHHH Afl.60 TeMHoro 060,n:Ka no nep11cpep11H, a HHor,n,a, Hao6opoT, HacTynaeT ,n:enHrMeHTa-

U:.H.H HOB006pa30BaHM51: . U:BeT onyxOAH 3aBHCHT OT KOl\.H'IeCTBa co-

.n.epJKaIQe roc.s:r B HeM IlHrMeHTa H MmKeT BapbHpOBaTh OT o6hI'IHOH Tel\.eCHOH OKpaCKH ,n,o p030BOro, KOpH'IHeBoro,TeMHO-KOpH'IHeBoroH acnH,n:Ho-qepHoro. MHo:lKeCTBeHHbre TeMHbre .n.oqepHHe o6pa30BaHH.H

-caTeAAHThI BOKpyr OIIyxOl\.H H ysell.H'-IeHHeperHOHapHbIX l\.HMcpaTH-

'ieCKHX Y3AOB .HBJ\5IIDTc.s:r no3,n:HHMH ,n:uarHOCTH'ieCKHMH H He6Aaro- n pHHTHhlMH rrporHOCTH~recKHMH npH3HaKaMH . B p.H,n:e CAYl.J:aes B KO- :>Ke HJ\H nO,ll,KO:lKHOH Kl\.eT'iaTKeHa pa3AH'-IHOMpaCCTO.HHHH OT OIIyxOl\.H Il0.HBl\.5I!OTC.H TIAOTHhie y3el\.KH - TaK Ha3bIBaeMbie T p aH3HTHhie MeTaCTa3hl.

KnuttuttecKcvt JCJtaccucpuKayust. Heo6xo,n:HMhIM yCl\.OBHeM

.l(l\..H ou;eHKH Kl\.HHH'-IeCKOH CTa,n:HH onyxOAH Cl\.YJKHT noAHoe HCCe'l:eHHe nepBii'IHOH onyxol\.H, a TaKJKe nOAYl.J:eHHe HHcpopMaIJ.HH 0 HaAH'IHH penrnHapHbIX Hl\.H OT,l(at.eHHbIX MeTaCTa30B c nOMOIQbID Kl\.HHH'IeCKHX, peHTreHOl\.Of'H'feCKHXRAH Aa6opaT OpHbIX MeTO.l(OB. Ou;eHKY rAy6HHhl HI-IBa3HH nepBH'IHOHMel\.aHOMhl npOBO,ll,5IT c nOMOIQhID TOTal\.h- HOH 6Honc1111 c nocAe.n:yroIQeH ou;eHKOH TOl\.IQHHhI onyxoAH (MeTo,n: EpeCAoy), rny6HHhl HHBa3HH (MeTO.l( K.llapKa), a TaK:lKe HaJ\lif'iH.H.H3BeHHOro nopa:>KeHM51: 3n11.nep MHca. Bee nepe'iHcAeHHbie napaMeTphr y'IHThrnaroT np11 ou;eHKe cTa,n:u11 MeAaHOMbI. EcAH no p e3yAhTaTaM KAHHH'ieCKHX, peHTreHOl\.Of'H'-IeCKHXH / HAH Aa6opaTopHhIX MeTo,n:os H CCAe,n,osaHH.H perHOHapHhie H OT.l(al\.eHHbie MeTaCTa3hl H e Bhl.HBJ\Sl -

283

IOTo:r, 6oAbHOro OTH OCSIT KI HAH II KJ\HHH'JeCKO CTaAHH M eAaHOMbr. K

III KAH HH'·I eCKOH CTMHH OTHOCSIT 60AbHbIX c KAHHH'IeCKHMH BAH peHTreHOAOrH'IHCKHMH IIpH3HaKaMH perHOHap H bIX, a TaJOKe caTeA11.HTHblX HAM T paH3MTHHX MeTacTa30B. BhIAeAeHHe OTAeAbHbIX rpy rr cpeAH 60AbHbIX c III cT atJ;tteH: MeAaHOMbI secbMa 3aTPYAHHTeAbHO no

npH'IHHeOTCYTCTBHH qeTKHX K p H T epHeB ou,eHKH 'IHCAaMeTacTaTHqe-

BKAJO'-!aeT CAyqau c OT)l.MeHHhIMM MeTaCTa3aMH A106oii AOKMH3al..l,HH; OT ,Zl.e /l.hHbie rpYIIIThl B ,n:aHHOM CAyqae ·ra10Ke He BbI)l.eASIIOT .

IlaTOMOpcpOAOr H"leCKaR KAaCCH$HKailBR. IlaT0MoptjJ011.o- rH'IeCKrul'KAaCCHtjJ1ncau,HH. yqHTbIBaeT .n.aHHbi e rHCTOAOrU'!eCKOroMC-

CAe,ZlOBaHHH IlOCAe '!aCTHqHOH Hll.H 110AHOH AHM tjJa,n,eH3KTOMHH, a

TaJOKe y,n:MeHHSJ: oT,n:a11.eHHbIX M eTacTa3os. Y 6011.hHbIX c I H II naTo-

MoptjJ0Aor11qecKo H. CTati:HeH M e A aHOM b l )l.a:HHble 3 a perHOHapHbie HAH

CTHbIX /l.MMcpoy3AOB , a Ta.IOKe KAHHM'ICCKOH H peH TreH OAOl'H'iCCKOH

ou,eHKH BepoSITHbIX O'IaroaoT.n;aAeHHl>IX MeTacl'a3oB.K III rraToMoptjJoAorH'!ecKotiCT2.ll;HH MeAaHOMbl OTHOC5IT 60AhHbIX c HaAH'!HeM perHOHapHbIX MAH BHyTpHAHMtjJaTH'iCCKMX MeTacTa30B (nocAe).J;Hee YT-

B e p :>K,ZJ;eHHe OCHOBbl.BaIOT Ha pe3yAI>TaTax rraTOMoptjJOAOrH'!eCKOJ:'O

HCCAe,n:dBaHHR). B rrpou;ecce HCCAe,tl.OBaHIDJ rraTOMOptjJOAOr IIOAC'IHTbI-

B a eT o6w.ee KOA.H'feCTBO AH Mcpoy3AOB p e3CIJ;HpOBaHHOI'O o 6pa3u;a, a TaIOKe 'iHCi\O nopruKeHHblX y3AoB. K IV cra,n.1111 OTHOC.HT 6oA.bHbl X c

Hall.H'!HeMO,n:H o ro RAH AByx OT,tl.aJ\.eHHh!X M.eTa cTa3 0B no ,n:aHHbI M rHC- T OAOl'H'i:eCKOl'O HCCAe,L{OBaHHSl.

M1-1eMottu'<ec1eoe npaeu.no «iPHI'APO»:

cpopMa BbJnyKJIM, IIpl1IIO,[J;HSITaSI Ha,[]; yposHeM KO)KM, 'ITO n:y•nIIe

Bcero Bi-!AHO np11. 60Kot101v1 ocne~em-rw. Me.rraHOMa in situ M aKpa111>Hru:I JieHTl1rMH03H aH MeJiaHOMa 6bIBa!OT IlJIOCKMMM .

A1'1:aMeTpKapaH,uawa (6,0 MM)

284

0 - OKpacKa ttepaBHOMepmrn: 6ecnop)J)l;o<rno pacn orro)KeHHbie

K Op11'Ii-reBl>Ie, qepttb1e, cepl>Ie, po30B1>1e 11 6eJTure yqacTKt1.

A e<teH.ue. BHoncrrH H x11pyprH'IecKoe AeqeHHe.

•OnnrManl>HbIM cnoco6 - TOTanbHruI 611ono1l'I;pacCT05IHlile OT Kprui:

orryxo;rn g o rpaHiiiu; p e 3e Kl\1111 )J;OJDKHO COCTaBruITb OT 1-2 MM AO 3-

4 cM.

•ECJrn: TOTanhtta5l 611oncID1 tteB03MO)l(Ha, ttanpiiIMep 113-3a KpyIIHbIX

pa3MepoB o6pa30BaHl1J'I, MO)!(HO orpaHtt"IT1TbC5l 11HI.(IDiiIOHHOM l1.ITT1

nyHKu;l10HHOM 611oncHel1 .

•ITpw 11Hl1~"13!10HHoi1 11 n yttKL\HOHHOH: 611ono111: eCJI11 orryxoJib BbI-

CTYnaeT Hag n one pxttccThIO KO)l<r1, BhI6VIpaIOT ca:MbIM BhI COKl1M yqa-

croK, ecrri-t OHa ITJlOCKall - CaMbrl1: TeMHhIJil.

285

•A,o;·h10BaHTHa5I xwMworepanwr nposo,o;wro1 6orrhHbIM c BbrcoKHM pwcKoM peu;H,a;wsa (To eCTb co CTa,D;l15IMM 3a6onesaum1 Ilb w Ill) nocrre xwpyprwqecKoro y,o;arreHIDI. nepB1iNHOi1 onyxorrw w scex BhI.mmeHHbIX MeTaCTa30B.

•Or,o;aneHHbie Me-racTa3hI (cTa,o;1'UIIV). ITpw oT,D;arreHHblx Me-racra3ax neqeuwe B nyqrneM cny~rae HOCHT narrwaTWBHbl'i1xapaKrep. Hennoxtte pe3ynhTaTbI p,aeT y,o;aneHT'1eAOCTfITHhIX ,a;rur x11:pyprwqecKoro BMeruaTeJibCTBa MeTacTa3oB. ITp111Me1urIOT MOHO- w noJIWXMMJ110Tepan:n10. 0µ;1-ra.Ko tta IV cTa,o;HM 3a6onesa1uu1 see Xl'1MMOTepanes11qecKv.e cxeMbI Mano::icpcpeKTMBHbI: peMHCCIDI B03HMKaeT Mettee qeM B 20% c.rrytiaeB, a BbI)KMBaeMOCTb he MelUieTC5I. nyqeBa5I Tepam~ OKa3bIBaeT TOJibKO naJ1JTI1aTMB1me p,e'i1CTBHe. Eonee nepcneKTWBHblM npe,!1,cras-

~eT~ aarrpaBrreuu oe o6nyqeHHe Meracra30B y-qacrm:1aMw (raMMa-

HO)I().

IIpoZH.03. O cHOBHbIM Kp:wrepHeM rrporHo3a npH Me11aH0Me

.srnMieTcsr pacnpocrpaHeHHOCTb onyxo11eBoro rrpon.ecca. EcAH Me11a - HOMa ,[(HarHOCTHpOBaHa TOAbKO B CTaJ.J:HH rrepBH:qff()H onyxo11H, TO 5-

AeTHSISI BbDKHBaeMOCTb COCTaBASieT 69-85 % , npH MeTacTaTW!eCKOM

AHMcporeHHOM pacrrpocTpaHem-m npon.ecca - MeHee 50 %, a n p u

HaAHqHH OTJ.J:aAeHHbIX MeTaCTa 30B eJ.J:HHHqHbie 60flbHbie )iillB)'TJ.J:O 3-x

AeT.

nPAKTl-1'-IECKlttlEHABl:>IKll1 no ~l<1C1...tt1nl11t1HE «~EPMATOllOnUI, BEHEPOJ10r111.SI »

1. MeTOAMKa onpeAeneHMR AepMorpaqnt3Ma

,nepMorpaclJH3M npe,n:cTaBASieT co6oH: cocy,n;i-1.cry10 peaKD.iiIO KOJKH Ha MexauuqecKoe pa3,n:proKeuHe, BbI3bIBaeMoe AHHeHHbIM ,z:i:aBAeHHeM Ha KO:>ey TyIIbIM rrpe.n:MeTOM. HopM<VlbH.bLU 0epAtozpa4Ju3M xapaKTepH3yeTCs:I o6pa3oBaHHeM lllHpOKOH p030BO-KpaCHOH IJOAOCbr, ucqe3a10r.u;eH: qepe3 1-3 MHH. IlpH KpacH.oM iJepMozpa!fJu3Me B03IHiKllla.SI IlOAoca UlHpOKaSI, B03BbII.lieHHaSI, .n:ep)KHTCSI JJ..O 15-20 MHH, conpOBO)KJ.J:aeTCSI AerKHM 3Y.IJ:OM (3K3eMa, IICOpHa3). IlpH 6e.noM iJep- M.OZpa!fJU3M:e qepe3 15-20 ceK. IlOSIBMieTC5I 6eAaSI IlOAOCa, KOTOpaSI HC'!e3aeT qepe3 5-1 0 MHH (HeH:po,a:epMHT, noqecyxa, aTonwrecKHH: ,a:epMaTHT). IlpH CM.eutal-tH.OM iJepM.ozpd'1Ju3Me KpaCHaSI ITO/\Oca CMeHSieTC5I 6eAOH. YpTHKapHbIH ,a:epMorpacpH3M rrp05IBMieTCSI B BH.ZI:e pe3KO B03BbilllaIOr.u;HXCs:I, OTe'IHbIX, llIHpOKHX IlOAOC, coxpaHSieTC5I B TeqeHHH 30-40 MHH.

286

JlHaCKOilHSI (BHTponpeccnR) ocyw:eCTBAHeTC5I nyTeM Ha,ll.aB - i\HBaHH5I Ha 3AeMeHT npe;:i;MeTHbIM CTeKAOM HAH CTeKARHHbIM wnaTeACM H .n.aeT B03MOJKHOCTb ;:i;mpcpepeHI.J,HpOBaTb BOCTiaAHTeAbHOe IIRTHO OT HesocnaAHTeAbHOro (reMopparwiecKoro, n i -i:rMeHTHoro). BocnaAHTeAbHoe IIRTHO npH JJ;HaCKOIIHH 6 1\e,ll.HeeT, a HCBOCIIaAHTeAhHOe TIO'lTH He H3MeI-IReTC5I.

IIOMUHTb, 'ITOB HOpMe 3AaCTH'lHOCTbH TOHYC K02KH Ha pa3HbIX yqaCTKax o6rn;ero IIOKpOBa y OJJ.HOro H Toro :>Ke 'lCAOBeKa He O,ll.HHaKOBbI. Y'lHTbIBaIOT TaK:>Ke B03paCTHbie H3MeHeHH5I KO:>KH: CHH2KeHHe Typropa H 3AacTH'lHOCTHy IIO:>KHAhIX AIO)l;eH . BecbMa IJ,eHHa IIaAbTiaIJ,H!<I npH runep3AaCTH'leCKOH KO)!{e. IlaAbIIaTOp HO MO:liiliO onpe.n;eAHTb IIOBbImeHHe HAH IIOHH:>KeHHe TeMneparypbl K02KH (p02KHC'roeBOCIIaAeHHe,

rAy6oKaH CTacpHAo.n;epMHf!, 3 pHTpo.n:epMIDI, 6oAe3Hb PeH:Ho, cKAepo - ,z::i:epMIDI H .n.p. ), pacnOAO:>KeHHe 3AeMe!-ITa (3IIH,ll.epMHC, .n.epMa, no.n.- KOJKHaH KAeT'laTKa), ero pa3Mephr, cpopMY, KOHCHCTeHIJ,H!O, CilaHH-

HOCTb c OKpy.>KaIOill;HMH TKaHf!MH, 6oAe3HeHHOCTb. IIpH OTeKe onpe-

.n.eAHIOT ero HHTeHCHBHOCTb. TaK:>Ke naAhnaTop uo onpe.n.eAHIOT HaAH- 'lHe CHMIIT OMOB cpAIOKTy-aIJ,HH (a6cIJ,ecc, rH.n.pa.n.emn) •H OTCYTCTBHe 6oAe3HeHHOCTH (TBe p ,ll.bI H IllaHiq>).

4.MeTOAHKa HCcneAOBa HHSI TaKTHllbHOH, TeMnepa-

TYPHOH H 6011e eoH ~yBCTBHTellbHOCTH KO>KH

,lJ.A5I onpe,ll.ei\eHIDI TaKTHAhHOH 'IYBCTBHTeAl>HOCTH IIOAb3YIOTC5I KHCTO'lKOH Hi\H KOMO"<IKOM BaTbI, KOTOpyIO npHKAa,ll.bIBaIOT K onpe.n.eAeHH OMY yqaCTKY KO.>KH, naIJ,He HT He .n:oA:>KeH BHJJ.eTh PYKH spa'-Ia,a JJ.OA:>KCH CKa3aTb 0 CBOHX omyrn;eHH 5IX.

,lJ.A5I onpe.n;eAeHH5I TeMnepaTypHOH 'IYBCTBHTeA&HOCTH

TI0Ab3YIOTC5I ABYMf! npo6HpKaMH, KOTOphre HanoAHeHhI XOAO,ll.H OH H TenAOH BOJJ:OH. 8THMH npo6HpKaMH noo-qepe.n;Ho npHKacaIOTC5I K nosepXHOCTH KO:>KH H Y3HaIOT y naIJ,HCHTa npo COOTBeTCTByrorn;ee omy-

rr~em1e.

,lJ.A5I onpe.n;eAeHIDI 6oAeBOH 'IYBCTBHTC.IU>HOCTHTI0Ab3YIOTC5I AI06hIM OCTpT>IM npel(MeTOM (qarn;e s cero 3TO o6bI'!Ha.SI HrOAKa) , KOTO-

287

pbIM Aer KO Ha,n:aBll.11BaIOT Ha )"laCTOK KO)KH H cnparnHBa IOT nau.HeHTa

o6oAeBbIX OlllYIII.emrnx.

5.MeTOAHKa onpeAeneHHe Typropa 111 3naCTH~HOCTH KO>KH

IlpOH3BO):(HTCSI ow;ynbI Bar-rneM (IlaAbll,aMH' 6epy T KO:>K)' B

CKJ\a,n:ey), a TaIOKe nyTeM rrorACUKHB8Hlill KOJKH H Ha,n:aBAHBaHHa Ha

Hee . 0 Typrope H 31\aCTH'U-IOCTH K OJKH MO:lKHO cy,ll.HTb IIO B pCMCHH

p acrrpaBAeHHa CKJ\a.Zl:KH Ha Tbl i\e KHCTH. IlpH xopoIUeM Typrope OHa

pacnpaB.l\5le TC.H M OMeHTaAbHO, npH 110HIDKCHHOM H y CTapHKOB .n:ep-

:lKCHHbIM TOeyCOM - npHCyTCTByroT MOPllI.HHbl, KO:lKH)'IOCKJ\a):(KY o6pa30B8Tb MO:>KHO, MMeIOTC.H i\OKaAbHbie oqarH .n:pR6AOH KO.lKH Ha i\Hll,C.

ATOHH'.rnas:r- KO:lKa - HCTOH'-ICHI-laR,.n:ps:r6t.as:r, IlOCTO.HHHb Je MOPIII.HHbl,

.n:p.H6i\OCTb oco6eHHO BblproKeHa B rrapaop6HTaAbHOH H rrepHOpaAbHOM 061\aCTH, CKi\a):(KH o6pa3y l-OTCH n p OH3BOi\b l -IO.

6. MeTOAHl<a npoeeAeHHSI nocKa6nHBaHHSI (rpaTTa>K)

II00Ka61111aaHHe (rpaTTCUK) - pacnpocTpaHCHHbIH .zi:uan ro -

CTH'-IecKHHnpHeM B ,n:epMaTOBCHCpOAOI'HH.IlpOH3BOJI.HTCSI OHO rrpe,n:-

KO:lKH; c IlOMOllI.bl-0 T10CKa6AHB 8 HH5! orrpe.n:ell5IeTC.H Cila.HHHOCTb "<J:eIUyeK H KOpOK c 31\CMeHTaMH HJUKei\C:>Karu:efr KO:lKHOH CbIITH, CTCilCHh c y - XOCTH MAH Bi\a:lKHOCTH KOpOK, xapaKTCp nosepXHOCTH KO:lKH rro.n: HHMH . I1Hor .n:a npM I10CKa6AHBaHHH OTMe"IaCT CSl 6oAC3HCHI-iOCTb (c HMIlTOM EeHbe - Meru:epciroro npH .n:ucKoH.n:Hofi KpacHoH BOA'-IaHKe). MeTO,LI; npHMeHSieTCH rrpH ncopH:a3e, .Zl:J\Sl KOToporo THilH'-IHbIcpeHOMe - HbI («CTe apHHOBOro IillT Ha», « IlCOpHaTK'le CKOH Hi\H TepMHHaAbHOH Ili\CHKH• H «TO'-Ie'-IHOroKpOBOTC'-CHHSI» Hi\.H «KpOBSIHOH pOCbI• ), rrpH pa3HOU.BeTHOM (0Tpy6eaH,1J.HOM) 1unuae, n a parrcopua3e . CAe1zye-r npe- ,n:ocTepe'-IbOT rrpoae,n:eHHSI nocK a6..urnaHHSI HOITeM, TaK KaK rrp H 3TOM B03M02KHO 3 a proKeHHe (,n;epMaTOMHK03, narryt.e3HblH CHcpHAH,LJ;).

7. MeTOAHKa nocTaHOBKH KO>KHblX npo6

Ko:lKI-lhie rrpo6br 51Bi\SIIOT cs:r o6III.errpH3HaHHbIM MeTop;oM 3THO - AOI'H"le KOH p;uarHOCTHKH aAAe prw-1ecKnx .n:epMaTo3oB. OcHOBHhtMH

288

u;elillMH KO)f{HbIX npo6 5IBlilllOTC.H Bbl.HBAeH11 e OCHOBHbIX MAepreHOB, He yCTaHOBAeHHbIX 110 AaHHbI M aHaMHe3a, H IIOATBep:lK",ll.eHHe HMH- 'YH. .H aAAepreHOB, npe.n:noti.araeMbIX Ha OCHOBaHHH ,n:aHHbIX aHaMHe3a.

KaneALHaH KOlKHaR npo6a: Ha KO:>ey Bl'IyTpenHeH: nosepxHOCTH npe.n:m~e'-Ib.H (cso6o,n:HyIO OT BhICb!IlaHHH) i iaHOC.HT KaIIJ\H HC-

c11.e.n:yeMoro Beru_ecTBa p a3HOH KOHU:eHTpau_11H . IlapaAAeAbHO CTaBHTC.H

p11pyIOT qepe3 2 0 MHH,YT, 2 4 H 48 qacoB c MOMeHTa HaHeCeHH.H Beru_e-

IIAoru_a,n;bIO 1 c M 2 , CAO)Ke HHYIO B 4-6 CAOeB. l1o,n:roTOBAeHHYlO CMtj:>eT-

ey I-mKAa,n;hIBaIOT Ha npe .n;IIAe'!be, HaKpbmaIOT K OMIIpeCCHOH 6 yMaroi1

npOBO.ll,HT '!epe3 24-7 2 'iac . TioAO:llillTCAbHaSI peaKIJ.lliI npOHBAHeTC.H no-pa3HOMY - OT He60AblllOH 3pHTeMbl HAH e.n;HHWiHbIX BhICbIIIaHHH

A O pa3AHTOH 3pHTeMbr c OTeKOM H Be3HKYAHU.HeH, HaMHOro BhIXO)l,Slru_e :H. 3 a n pe.n;e&I TeCTOIIAacTa. 01.(CHKa KarreAbHbIX H KOMrrpecCHhIX rrpo6 npm1.3BOAHTC5I COrAaCHO rrpHBe.n;eHHOH Ta6AHI.(e.

OqeHKa Kanen&Ht:.tx 111 1<0MnpeccH&1x npo6

289

CKapHcl>HKaD.HOHHaR KOlKHaR npo6a: Ha BHyrpeHHeH no-

BO,ll;SIT no KOJKe .D;Be napaAAe11.bHhie u.apam1Hb1 .D;AHHOH no 5 MM c npoMeJKYTKOM MeJK.LIY HHMH 3 MM 6 e3 noBpe)f{,D.eHH.H KpoBeHOCHhIX cocy- ,ll;OB KO:>KH. "Y:epe3 5-10 MHH Kaili\.H CHHMaIOT crepHil.hHbIMH BaTHhIMH T aMilOH aMH, KOTOpbie 6epyrcg, KaK H CKapH¢HKaTOphI, OT,Aei\.hHO ,ll;ASI

BHyTpHKOJKHaJI npo6a: ,ll;ASI Ka)f{,D.Oro aAAepreHa Heo6xo.n;HM · OT,O:eAhHhlH ry6epey11.HHOBhlH mnpm.i; H TOHKa.H HI'J\.ac KOpOTKHM OCTpHeM. Co6J1.IO,a:aIOTCH s ee yCAOBHSI, KaK H npH cKapu¢11Kau.1rnHHOH npo6e . KoJKY HaTIInrnaIOT KHH3y, HrAy BBO,ll;SIT no.a: He60AhUIHM yrAOM

290