Nineteenth Century Medical Guide

Chapter 112 109. Amputation is not easy
Friedrich-Wilhelm von Lieben, a German jazz with a slightly weird name.

Based on Ignatz's experience in high-level affairs, leaving aside his rogue-like behavior, the name itself is problematic.He knew many German and Austrian nobles who had never heard of such a noble surname, and none of them would embarrass a married commoner woman for their own desires.

Because it will damage your own status.

But doubts are doubts, and Ignatz has no motivation to take action to investigate further. Today, he came to the Riverside Surgery Theater not for him, but to see Carvey's amputation.

Amputation is the basis of surgical medicine, and it is also an important point that must be mastered.

A qualified surgeon may not perform any abdominal surgery, or may not be familiar with or even understand facial plastic surgery, he may not know Latin, French, or most of the detailed anatomical positions of the whole body, it does not matter. But definitely not without amputation.

Even for barbers who still work in rural barbershops, amputation is a must-learn.

Because there are so many people who need amputations.

Austria was already mired in the quagmire of war, and it was not easy for soldiers to keep their bodies intact.On weekdays, open fractures, wound infections, and even severe paronychia and erysipelas all required amputation for treatment, otherwise the gradually aggravated infection would slowly swallow up the patient's life until death. 【1】

In addition, diabetic foot caused by diabetes, terminal necrosis caused by long-term compression, congenital deformities of limbs, and amputation injuries caused by various machines also require amputation.

Before the advent of antibiotics, amputation was enough to be classified as a large category of surgery, and each joint was a cutting point, which was also a point of knowledge for surgeons.

Amputation is not as easy as the literal meaning. It is also an amputation, and the amputation of the barber cannot be compared with the orthodox surgeon.And those young doctors who have graduated for a few years and finally got the scalpel are many grades behind Carvey.

Considering Li Ben's special status, Cavet specially set the operation in the morning.

At 8 o'clock in the morning, Li Ben was reluctantly sent to the preparation room of the surgery theater.

Everyone can see his nervousness, helplessness and dissatisfaction with his rough fate, but things have reached this point, and he can't think of any better way than to accept it.At least in the past few days in the postoperative ward, apart from listening to other people's ridicule and abuse, I was more convinced of Carvey's surgery.

0% mortality rate, 20% postoperative incision ulceration rate, unique in the world.It was the luck of misfortune again, the last time he had the same thought was when his neck was just stitched on.

He smelled the bloody smell from the tip of his nose, and wanted to struggle one last time: "Doctor Carvey, can I really lose my leg?"

"You've asked me a dozen times."

"I think it's better to try debridement again, in case it grows well."

Carvey also wanted to debride and save limbs. It can be said that any doctor with medical education would not want to amputate a patient, especially this kind of amputation to prevent the infection from worsening.Standing on the amputation operating table, no doctor will think that the operation is beautiful when watching the limb being cut off the patient's body.

Because this is just wiping the ass of the previous failed treatment, and there is no sense of accomplishment at all. 【2】

But if you put aside the subjective psychology and only look at it from the perspective of surgical operation, the technical content of amputation is not low.The main difficulty lies not in cutting meat and sawing bones during the operation, but in judging the damage before the operation, choosing the cutting path during the operation, and suturing after the operation.

Typical type of surgery where the decision trumps the operation.

"Don't think about it." Carvey drew several solid lines on his leg with a pen [3], "Even if you do debridement, it will only get worse, and now you can still save your butt. At that time, let alone the buttocks, I'm afraid you may not even be able to save your life. After all, the higher the amputation is, the more dangerous it is, and the chance of large incisions festering is higher. You don't want the wound to rot any longer."

Li Ben's heart was ashamed.

He didn't sleep all night last night. He couldn't figure out why he lost his leg because he just came to Vienna to pan for gold.Now that I have no money, I have to live with crutches for the rest of my life.
At this time, the host of the surgery theater knocked on the door and walked in: "Dr. Carvey, are you ready? You can enter now."

"Get ready, let's start." Carvey said with a smile, "It's quiet in the early morning, and even the entrance introduction is saved."

"I see there are still people in the auditorium, according to the regulations."

"I know, they should be acquaintances, there is no need to waste time making introductions." Carvey patted the host on the shoulder, "If you are free, why don't you and Bergett help move things, these cleaning and disinfecting instruments and medicines It's pretty heavy."

"okay, I get it."

In addition to Ignatz in the auditorium, there are several colleagues who need to perform surgery on stage today. After reading the surgery program, they all want to see the strength of Kawei's surgeon.

Among them is Hills, who is about to preside over the laparotomy.

He found Ignatz, hesitated for a while, and then left the two assistants and sat beside him.Hills knew that Ignatz was in a bad mood, and that his departure had weakened the surgical strength of the Municipal General Hospital to a certain extent, so he needed to apologize.

"Teacher, I am really sorry to leave the hospital suddenly. I have learned a lot from your side, but I feel that I need a broader space for development."

These clichés seemed to have been prepared early in the morning, and he said a lot of them.

It's a pity that Ignatz has long lost interest in this student, and his face is full of perfunctory: "I see, let's see the operation."

Li Ben was admitted to the hospital later, and Sears didn't know his physical condition. After listening to Carvey's simple description of his condition, he realized that Li Ben was the lucky one under the complicated trauma suture operation.

"it's him?"

"Yes, what's wrong?"

"Only one of the five incisions is rotten?"

"seems like it."

Hills replaced surprise with silence, his eyes fixed on the operating table: "He's going through these boring disinfection procedures again."

"I remember you should have seen it during the cesarean section."

"I have seen it, but I still don't understand why I do it. Why do I have to wash my hands repeatedly? Is it not enough to wash once? Why do I have to wipe the same surgical area repeatedly? Is it not enough? And why do I have to spread from the inside out?" ? Why is the area of ​​the second wipe smaller than the first one”

There are too many whys in Hills' mind, and Ignatz can't figure it out, but he chooses to believe: "The postoperative recovery ward of the Municipal General Hospital is the evidence. As for the principle, he will write a paper and publish it."

".Wait, what's that?"

I saw Bergett moved a machine and pointed it at the audience auditorium and the air around the operating table: "This is the miasma purification device invented by Mr. Liszt. It has been demonstrated during the regular surgical meeting discussion. I specially imitated it. One. The principle is very simple, that is, the disinfectant is hydraulically formed into small water droplets and sprayed in the air."

Hills looked at the water bottle, which resembled a modern watering can, and always felt absurd: "Why does he always think that Liszt is right?"

"Since we admit that there is miasma in the air, it is logically no problem to use the corresponding disinfectant to deal with miasma."

"Can disinfectant really extinguish miasma?"

Ignatz sighed: "I have to leave it to you after the operation, and I can't answer it."

Bergert was the first assistant in the operation, Melen was the second assistant, and Sarsen stayed in the preparation area. The specific division of labor seemed to be decided by a deck of playing cards this morning.

Carvey still chose high-concentration alcohol and bleach as the main force of disinfection this time. After Li Ben fell asleep, he placed a hemostatic compressor on the root [4], and then the scalpel quickly cut into the skin.

"The day before yesterday I participated in the regular discussion meeting of the College of Surgery, and someone mentioned the 'common iliac artery compression hemostasis method', which saves time and effort, but it is easy to cause double ulceration. Today I will separate the skin, muscle and blood vessels layer by layer, Expose the incision to the front of the amputated femur, then amputate the femur and continue exposure to the rear."

In just two sentences, Carvey has already sutured two blood vessels: "Everyone should have encountered the problem of incision ulceration after amputation. This is actually the product of a combination of multiple factors, the most important of which is It’s just a misjudgment.”

Having said that, the scalpel has come to the front of the femoral artery and vein.

Compression cannot completely block the blood flow, but under Carvey's meticulous anatomical separation, the ligation and separation of blood vessels is very beautiful.In the eyes of everyone, Carvey's operation did not have an exaggerated range of operation. He just buried his head, and the blood vessels were processed in a short while.

"The femoral artery and vein are very thick, and a single suture is not enough to block the blood flow. In order to prevent avulsion and collapse of the suture, I used double suture ligation."

Carvey cut off the severed blood vessel, and cut off the sciatic nerve behind it, and then quickly cut the flesh on the back side according to the previous method.His hand speed wasn't that fast, and he couldn't even rank among the top three in the audience, but there was one thing that no one could match.

That is blood loss.

The tedious repeated dissection of soft tissues gave Carvey an advantage that only modern surgery can achieve, minimal blood loss.After he cut all the flesh, there was not much blood left around the operating table, and the leather skirt in front of him was as clean as new.

This quiet surgical feature did bring a different experience to several colleagues on the stage, but his choice of amputation plane was criticized.

"Bergett, give me the bone saw."

"Give."

Even though he has been working here for more than half a month, Carvey's operation style still follows the modern concept, and even if the amputation is performed, the residual limb will be preserved as much as possible.In this way, there will be room for artificial limbs in the future, and the dressing and sitting posture will be more beautiful.

If the incision is infected according to the method similar to Ignatz, the entire femur must be excavated. 【5】

But Carvey left a section for Li Ben, as a thought for him, and at the same time showed his amputation skills.

"Following Mr. Li Ben's desire to preserve the limb as much as possible, I made some changes to the thigh amputation. I kept the femoral neck and joint, and left as much flesh as possible to leave some room for him to make a prosthetic in the future. "

This approach has clearly been questioned.

"Dr. Carvey, you lack experience in amputation. The amputation site is too low."

"Yes, amputation cannot be done softly. Once the heart is soft, the incision is too close to the injury and it is easy to fester. If ulceration occurs, the patient will have to undergo a second amputation. In fact, not many people can bear the second amputation."

Hills also held the same point of view: "Mr. Ignatz, don't you think his approach is too radical? The upper edge of the ulcer is very close to the incision he chose, and the second ulcer is inevitable. The selection of the amputation plane is so hasty, and it is the patient who suffers in the end.”

Ignatz had the same idea, but he was still willing to say a few words: "Don't worry, he has his reasons for making such a decision."

"It's nothing more than a prosthesis. In my opinion, there is no need for a prosthetic leg at all."

Ignatz stopped talking, and the right to speak was still in Carvey's hands: "Everyone, don't be impatient. Of course, I know that amputation needs to be as high as possible, so as not to cause secondary ulcers. But this is just a surgeon. The helpless move after being unable to clarify the damaged platform is to escape."

"What did you say?"

"What do you mean?"

Carvey picked up the bone saw with a smile: "If according to your statement, all calf injuries will be treated with patellar plateau resection, and all thigh injuries will be dug out of the femoral head. What technical content does such an operation have? A bone still needs skill, right?"

There was no sound in the auditorium, and there was only the strange sound of the bone saw teeth repeatedly touching the femur in the arena.

Carvey certainly understands what they mean. In fact, modern orthopedics often encounters cases where one operation fails and a second or even third amputation is required.

Many orthopedic surgeons have made the low-level mistake of being soft-hearted and fluke when making decisions, but those who can really complete the amputation of large limbs at one time and do not do it twice are all amputation masters.

What this requires is not superb surgical skills, but a strong judgment on the damage platform of the extremities.

Each stump has its own ideal amputation plane. Which tissues have been necrotic and which are still usable, you need to know at a glance.If the judgment is wrong, what will be sutured is lifeless necrotic tissue. Even if the disinfection and anti-infection are done in place, it still cannot prevent the necrosis of the incision.

Carvey had that experience, because the trauma center has seen so many amputations.

Hay cutter, threshing machine, tree cutting machine, car accident rolling, fan cutting, steel pipe puncture, glass cutting, meat processing dividing machine, high pendant, etc.
He couldn't judge the vitality of the stump muscles at the beginning, and he also underwent amputation operations that disappointed him.At that time, his teacher told him that the operation should not be rushed. The amputation site can be opened first, and the wound can be debrided several times. When it is found that the muscles are not necrotic, the final suture can be done.

This kind of practice has become experience over time, and now Carvey can judge the activity of the muscles as much as possible from the cause of the injury and the appearance of the wound.

As for Li Ben's simple infection, it is easier to judge.

"I have already done the disinfection work before the operation, and the miasma in the air will not affect Mr. Li Ben's wound." Carvey explained, "And after the operation, this disinfection work will still continue, I can tell now Ladies and gentlemen, the chance of this amputation wound festering is about zero."

This is not his boasting, but the real data calculated by Dr. Liszt.

The bone saw that Ignatz gave didn't work very well, and Carvey wasted some time on the femur.After he cut off the bone and took off Li Ben's entire left leg, he did not directly suture the muscle flaps on both sides of the fish's mouth like other doctors.

"Bergett, pull the flesh on both sides." Carvey looked at the preparation area, "Sarsen, give me the file."

"The file? Where's the file?"

"It's at the bottom of the box, and I wrapped it in a clean cotton cloth," Carvey explained. "I need to smooth out all these sharp femur stumps."

(End of this chapter)