Nineteenth Century Medical Guide

Chapter 142.
In modern mandibular resection, due to the large area of ​​maxillofacial bone loss, autologous bone grafting is often selected according to the patient's request.That is, a section of bone (mostly hip or fibula) is taken from the body, together with the surrounding musculocutaneous flaps and blood vessels, and transplanted into the patient's mouth.

The success of autologous transplantation is related to the smooth blood supply.

Limited by the fineness of the suture needle and thread, it is definitely impossible to do this kind of small blood vessel anastomosis with a diameter of less than 5mm. It is most convenient to directly use ivory to do simple filling.

However, for bone shaping, Hyundai chooses to use computer-aided design to cut long bones into small sections, and then use titanium plates to make connection arcs.In the 19th century, it relied on some personal techniques full of artistic sense. From casting molds to subsequent cutting and polishing, the most famous sculpture masters in Vienna will be fully responsible.

There was no lively scene of Kavey just now in the operating area, but Kavey's point of view shocked everyone's brains.

The operation of making ivory into the upper jaw and stuffing it into the face is already avant-garde. It doesn't matter whether the connection is firm or not. As long as it can be done, it will be a monument of maxillofacial surgery.Now adding metal plates and rivets to fix it, it is outrageous to think of the human bone surface as an iron warship.
But it seems to work.

A good idea can always arouse a lot of reactions, and soon several doctors who are good at plastic surgery in the audience took out their notebooks.Without asking too many questions, they could derive many solutions to the artificial upper jaw from this idea.

But after all, what surgery does is not repairing industrial machines. No matter how novel the idea is, it still comes down to the same problem in the end, that is, how to sterilize the metal plates and rivets, and what to do if there is an infection?
Items stuffed into the skin and flesh are not like surgical incisions, and can be opened and re-sterilized.If there is inflammation and swelling in the body, incision and drainage are relatively trivial, but permanent removal of the bone is relatively difficult.

Just like Charles had the same concerns before.

After all, doctors are solving patients' pains, not creating troubles.If the expensive ivory can't be done once and for all, or at least it can't solve most of the troubles with a high probability, then what's the point of using it to make it?
Carvey also knows this, what he wants to do most when he travels here is antibiotics.

It's a pity that there is a very high threshold for drug production, and the production of antibiotics is really troublesome. Savarin and Mattick have a serious shortage of labor in the laboratory. Now it is the limit to be able to verify the existence of puerperal microorganisms.

"If carbolic acid is used to soak ivory for a long time, I don't know if it is feasible."

Watman nodded, satisfied with this method, but it was not enough: "The ivory is actually okay, the trouble is the incision in the mouth. After the mandible was removed last time, it is easy to deal with even if it festers, but now it is in the mouth. .How to ensure the disinfection of the mouth? Do you give him carbolic acid every day?"

"Of course not. I think gauze soaked in carbolic acid could be used as a packing."

"It's a bit toxic." Watman shook his head. "I've always been skeptical about this thing since the voles raised by Kavey died of long-term stimulation by carbolic acid."

"I'm afraid high-concentration alcohol won't work either."

"Since neither of these two works, bleach will not work."

"Try carbolic acid first, the concentration is not high, and try to make it as dry as possible." Carvey said at this time, "In addition to packing gauze, more washing is needed, in addition to washing with normal saline, there is also disinfection. liquid flushing."

"For what?"

"Those three can't be used in the mouth."

"Recently, after studying the thesis of French chemist Tanner, I found that a strong oxidizing compound invented by him can effectively inhibit the growth of microorganisms [1]." Carvey said, "After testing, it was found that at 3% It is harmless to humans and animals at low concentrations, and can even be used on wounds, so I think it’s worth a try.”

"You invented a new disinfectant again?"

"It's not an invention, it's a discovery," Carvey explained. "This oxidizing agent is safer than carbolic acid, but it's easier to decompose."

Watman listened to Carvey's suggestion. The new disinfectant sounded good, but it still couldn't completely solve his doubts.Large defects and wounds left after maxillary resection cannot be resolved by irrigation.

He suddenly looked at Charles beside him: "By the way, can the palate guard you mentioned just now be made bigger?"

"What do you mean?" Charles stopped what he was doing.

"Is it possible to put carbolic gauze in the detachable palate guard and dental tray, so that the upper wound surface can be protected."

"It's okay, but it's a bit heavy."

Watman sighed: "The patient is considered lucky. If the tumor grows a little higher and the infraorbital wall is removed together, I don't know what to do with his left eyeball. According to the anatomical structure, there is no The infraorbital wall unsupports the orbital contents, including the eyeball." [2]

"It will fall."

"Definitely."

"If this is the case, palate guard + gauze packing should also work."

"Wait for the soft tissue to grow out slowly?"

"Perhaps, this case of maxillary resection is also done with my determination, and I have never seen the scope of resection expanded."

The operation time was not long, and the maxilla was cut off in less than an hour.The result of the operation was not bad, but the process was as rough as Olgi's.The place where the bleeding should be stopped was not stopped, and the place that should be carefully separated was taken away with a knife.

Although there are many branches of surgery, and there is not much connection between the various departments, the basic techniques of surgery are still interlinked.

The blood supply of the maxilla is richer than that of the mandible, and the amount of blood loss is relatively large during the operation, especially during the cutting process.If Carvey was to do it, he would definitely try his best to stop the bleeding. If possible, he could also ligate the external carotid artery first, which can greatly reduce the amount of bleeding. 【3】

As for the opened muscle skin, Wattman also failed to protect the blood vessels, and there were several bleedings that were unnecessary.

There were no accidents during the operation, and it was a success in everyone's eyes, but the real result can only be judged after the patient recovers.

Watman was not interested in suturing the second half of the musculocutaneous after resection, so he gave them all up to his assistants, and as the chief surgeon, he only glanced at them for a while.

Compared with the drastic surgery, the discussion and interaction time with the auditorium after the operation took up a lot of time.If the host hadn't come in and said that the next patient had arrived in the waiting room, Watman might still be able to chat leisurely.

"Since being inspired by Dr. Carvey last time."

Watman was still watching Charles soak the bones with carbolic acid, and felt wrong as soon as he said the first sentence, and looked up at Carvey in the auditorium: "I am always inspired by you, and the maxillary resection is also , eyelid repair too.”

"The dean is absurd."

"Don't praise me, the idea is indeed what you thought of first." Watman didn't mean to win people's love. A whole new kind of surgery."

Carvey wanted to try it too, but it was a pity that the Municipal General Hospital didn't accept many plastic surgery patients.

And his famous young surgical genius not only has to deal with medical school studies, but also has to deal with experiments. After returning to the hospital, he is also devastated by appendicitis and cesarean section.Especially the cesarean section, counting the total of eight in the month just now, it is really a master of obstetrics.

"Then there is no way." Watman was a little proud, "Since the surgical meeting, I have been looking for a repair method for simple ptosis. After several attempts on cadavers, I am now sure that the flap transposition method is completely feasible. "

At the regular surgical meeting, a patient with drooping upper and lower eyelids was discussed.

While others were still struggling with which of the upper and lower eyelids to do first, and which one was more difficult to deal with, Carvey had already thought of the complementary repair method of the upper and lower skin flaps, which greatly stimulated Watman's slightly dull old-fashioned surgical thinking.

He quickly figured out how to adapt the flap transposition method to other patients with drooping eyelids.

"Since it's a serial show, let's save the host introducing that set of things. Hurry up, everyone." Watman invited the patient in first, "The next patient is an assistant I just hired for the School of Surgery. Work hard and be a good person.”

A young man walked in from the gate, wearing a simple gray cloth short coat, a white shirt inside, and an ordinary peaked cap on his head. He seemed to be in his early twenties.

Compared with the two patients who just pushed in, his body is much healthier.Breathing smoothly, walking vigorously, and looking like the audience present.The only fly in the ointment is that the lower eyelid of the right eye droops, that is, lower eyelid eversion.A piece of red conjunctiva was exposed, which looked like heavy makeup, very weird.

"Hello, everyone." The young man smiled and waved his hands to the stage, looking very relaxed, "So this is the theater of surgery. I'm so excited."

"First time?"

"Yeah, I always wanted to come here after earning money to see how exciting it would be. I didn't expect this wish to come true before I made much money." The guy didn't have much scruples about the blood-stained surgical chair. When he found that the blood was dry, he sat on it directly, "Is the operation here later?"

"Yes, you will inhale ether and sleep, and when you wake up, the operation will be completed."

"It's amazing." The boy asked curiously, "Shall we start now?"

"It's still early, the previous operation just ended, and the assistants need to do the necessary cleaning work." Watman glanced at the clock, "And the scheduled time is at 9 o'clock, we still need to wait another 15 minutes for the audience to arrive Let’s start after it’s all in place. Tell me about your experience of lower eyelids going from slightly drooping to severe eversion, what made it so loose?”

"Scalds from childhood."

After years of precipitation, the melanin on the burn has been very light, but if you get closer, you can still see some marks on his right cheek: "After the burn healed, I felt that the lower eyelid of the right eye would go down. I can't control it. This appearance has made me feel inferior for many years, and I still can't find a girl who is willing to marry me."

"Permanent damage from the burn." Watman patted him on the shoulder and comforted him, "I will help you fix it."

"Thank you, Dean."

The young man's lower eyelid eversion was so severe that it really required surgery.

Watman first drew a folded line on his face with a pen [4], representing the path of the knife to be performed: "This is the skin flap transposition I am going to do today, looking for a complete skin in the corner of the eye, and cutting it open. Make a flap. Then transfer it into the lower eyelid after it's cleared of scar tissue.

When the operation is over, his lower eyelid will be back to normal, replaced by just a new injury in the corner of the eye, which can be covered with hair. "【5】

The operation process is not difficult, and Watman also has rich experience in this kind of repair operation. After the audience has settled down, the operation officially begins: "Nurse, start anesthesia."

The young man sat on the operating chair just like the patient just now, leaning his head back on the soft cushion, and put on the mask sent by the nurse with peace of mind.His heart was full of excitement and anticipation, and after the operation was completed, he took a look at his new eyelids in the mirror.

The ether slowly volatilized in the anesthesia container, and poured into his nasal cavity, respiratory tract, and lungs through the rubber tube.

The ether began to diffuse from the alveoli into the blood, and soon the effect appeared. The young man felt dizzy, his vision was blurred, and his ears could not hear clearly.Gradually, he began to lose control of his body, and soon "fell asleep," as Watman put it.

But the effect of ether has not weakened. It was just an analgesic period, followed by a cortical excitement period. The young man who lost consciousness began to struggle, hold his breath, cough and vomit.

This is a normal phenomenon in the eyes of all the surgeons in the field. Most of the patients they take over will go through this period, including Kavey.

Soon the ether continued to act on the cerebral cortex, and the intercortical brain began to inhibit it. The unconscious excitement just now gradually disappeared, and the boy really calmed down. The ether reached the anesthesia period for surgery.

But unlike other patients, the anesthesia effect this time seems to be stronger.

Soon the ether completely inhibited the diencephalon, the midbrain and spinal cord began to be inhibited from bottom to top, and the intercostal muscles were paralyzed.This reduces the breathing rate, but not enough to deprive the patient of breathing, and the patient is still alive, which is also the state of a small number of patients when undergoing surgery.

But the nurse seemed not to pay attention to the dosage when pouring in the ether this time, and it might have been because of a slight hand shake. In short, the inhaled amount is larger than before, and the effect will be deeper.

The spinal cord began to be further suppressed, followed by the pons and medulla oblongata, the diaphragm began to be paralyzed, all the respiratory muscles were paralyzed, and breathing stopped.Once breathing stops, the whole body loses oxygen supply, and the heart quickly loses its beating function
"Maldos! Maldos!!!"

(End of this chapter)