Nineteenth Century Medical Guide

Chapter 147. 144. Positioning methods that do not rely on imaging
[This chapter needs to be sorted out today]

Herniated intervertebral disc is no longer a troublesome problem in modern times. Early detection and early treatment can mostly be relieved conservatively.Surgical removal of the nucleus pulposus can only relieve symptoms, but cannot change the changes in the bones. The focus of conservative treatment is to maintain correct sitting and standing postures, reduce the frequency of bending over, and prevent strenuous exercise and labor.

However, for patients with severe lumbar and leg nerve pain like the old marshal, the protruding nucleus pulposus has severely compressed the spinal cord nerves, and only surgery can relieve the pain.

Ludwig is over 60 years old, anesthesia is risky, and surgery must be difficult.Although Kavey has dabbled in spinal surgery, at least he is much more familiar with extra-maxillofacial surgery, lumbar disc herniation is not a common operation in emergency surgery.To get this operation done, Carvey needs to be fully prepared to rule out all possible accidents as much as possible.

Of course, before deciding on the operation, Carvey still needs to get another thing done, and that is the location of the lesion.

Modern imaging examinations are available for precise positioning. It can be seen between which two vertebrae the problematic nucleus pulposus is located, in which direction, and whether the protrusion is serious or not.

The main purpose of imaging examination is to show the progress of the disease more intuitively, and to eliminate some possible pitfalls and difficulties before the operation.But even without imaging examinations, the location of the herniated intervertebral disc of the old marshal can be determined by relying on the distribution of the lumbar nerve control area.

What Carvey needs to do is a more precise positioning, so he needs to do a physical examination of the waist, buttocks and lower limbs, which is also a compulsory part of the medical examination every year.

Holding a piece of paper given by the housekeeper in his hand, he first roughly drew the old marshal's waist and legs with a quill.The thighs and thighs were divided into regions, marking the corresponding spinal cord planes, and there was a blank space on the side to write the corresponding pain, touch and muscle strength. 【1】

"Old Marshal, I'm going to do a whole set of examinations." Carvey first explained what he was going to do, "The main purpose is to judge the location of the lesion. When the time comes, the operation does not need to make a too long incision, and only needs to be operated on the location of the lesion." Just do it."

The old marshal was afraid when he heard the inspection: "There is still an inspection? It can't be the one just now, right?"

Carvey smiled and said: "It's okay, now that the type of disease has been determined, the next location check will be much easier."

Judging from the symptoms, Ludwig suffered from unilateral sciatica and low back pain, and the straight leg raising test was positive, which is a typical manifestation of lumbar disc herniation.Low back pain itself can roughly find out the location of the herniated intervertebral disc.

Kawi basically determined the position between L2-S1. [L lumbar spine, S sacral spine]
Judging from the location of the lumbar pain, it seems that the L1-L2 gap has been ruled out, but further verification is needed before drawing conclusions.Carvey first found the front and middle areas of Ludwig's thighs, and gently drew long lines with his fingernails: "How does it feel?"

"It doesn't hurt."

"It doesn't hurt. I mean, is there any difference in the feeling of the thighs on both sides?"

"No." [L1-L2 no problem]
Carvey's hands went down, from the medial femoral condyle to the medial malleolus: "What about these? Do they feel the same?"

"All the same." [medial femoral condyle=L2-L3, medial malleolus=L3-L4]
"Okay, next is the outer calf"

Kavi's finger moved to the calf, and Ludwig immediately responded: "Wait, it feels different here! I can hardly feel the right calf!!"

"It feels abnormal." Carvey exerted some strength on the outside of the right calf. Seeing that he was still shaking his head, he tentatively determined the plane position of the herniated intervertebral disc: "The outside of the calf is L4-L5."

Carvey made a mark on the paper, then moved his hand to the top of his foot.Before he could open his mouth to ask questions, the old marshal already knew the inspection routine, and replied: "I don't feel it here."

"What about the pain?"

"Pain can be felt, but very mild."

"L5-S1 also has problems"

Most of the intervertebral disc herniation of ordinary people is a single single plane, and the compressed nerve root is only manifested as a decrease in pain, and there will be no such serious loss of pain.Carvey can't make a complete conclusion based on simple sense of touch, and then needs to do some necessary reflexes.

First there is the knee jerk reflex, the reflex of the old field marshal is present. [Explanation L2-L3 is no problem]
However, there was an abnormality when doing the ankle reflex. The ankle reflex was very weak, almost as if it had disappeared. [L5-S1 has a problem] [2]

"Your Excellency Marshal, try to hook your feet upwards."

"Hook feet."

With the help of Carvey, the dorsiflexion of Ludwig's right ankle joint is also normal, indicating that the strength of the extensor muscles of the foot is normal [L3-L4 is no problem].But when asked to hook his toes, he shook his head: "Only the left foot can do it, the right foot can't."

"The dorsi extensor muscles of the toes are weakened, and there must be a problem with L4-L5."【3】

Relying on sensation, pain and some necessary reflex checks, Carvey basically locked the location of the lesion, which is at L4-S1, and the two intervertebral discs may have herniated.However, for the sake of safety, he still needs to do another muscle strength test: "Your Excellency, Marshal, hold the table and stand up slowly."

"It's a bit difficult." Ludwig couldn't walk smoothly, but he still obeyed Karvey's request. With the support of the housekeeper, he slowly came to the table and straightened his body. "What's next?"

"Raise your right thigh." After Carvey finished speaking, he pressed his hand to his thigh, "You need to resist my downforce and keep your body straight."【4】

Ludwig's movement was very difficult, but the necessary iliopsoas muscle strength was still there, and Kavey's downforce did not crush his raised thigh: "Not bad, L1-L2 must be fine."

"So what's the problem now?"

"I can basically lock the position." Having said that, Carvey still needs to make some necessary inquiries, "Did the pain radiate directly from the waist to the thigh during the attack?"

"Correct."

"Worse when you cough or strain to have a bowel movement?"

"sometimes will."

"After a round of inspection, it can now be concluded that it is a very serious multiple herniated nucleus pulposus, and there are two problems." Carvey looked at the picture and gently pressed on Ludwig's lower back, "Here, and here"

Just a simple press was already unbearable for the old marshal, and he could barely keep himself silent.He wanted to move away, but the pain itself restricted many movements, and in the end he could only bear with it: "It hurts too much, haven't you checked yet?"

"almost."

In order to fight against lumbar disc herniation for many years, Ludwig has been leaning forward or bending sideways to avoid pain, and the spine is also bent sideways due to this strange posture.Coupled with his age and increased bone fragility, what Carvey has to consider is not only whether the operation can be completed, but also his postoperative recovery.

The purpose of surgery is to alleviate the original pain with the damage that the patient can bear. If the surgery relieves the pain, but brings the result that it is difficult to stand up or even take care of oneself, it is better not to have surgery.

Since Carvey has received the operation, he must ensure that Ludwig can walk like a normal person after the operation.

"I'm afraid the operation time will be postponed for a few days." After all, Carvey is not an orthopedic surgeon who specializes in lumbar disc herniation. "I need to make some preparations before the operation."

"No hurry, no hurry." Ludwig sat back on the bed with the help of Kawei, put on his shirt and pants with a smile, "I don't care, just take your time."

"Is it good to take your time?"

"Uh, I mean it's good for you to make more preparations to prevent accidents."

"I will try my best to arrange surgery for you in a week."

"Send a letter when the time is confirmed, specifying the time and location of the operation, and I will naturally go there when the time comes."

This operation has been basically decided, but before that, Carvey still needs to confirm whether the old marshal is willing to go to the theater: "According to regulations, the hospital only requires civilians to enter the theater. You are a marshal, which is different from civilians. You can freely choose the location of the operation. and the number of onlookers.”

"Let me decide the location?"

"Correct."

"Can you even determine the number of onlookers?"

"Yes, you can refuse to enter the operation theater and operate in your own bedroom." Carvey said, "This is the privilege given to nobles by the Municipal General Hospital. Even if this operation will attract surgeons from all over Vienna to watch, I will This rule must be followed.”

After all, Ludwig was the commander in chief of the entire army, and it would be embarrassing for others to watch the operation.

But the sentence just now made the old marshal feel strange: "Huh? What does it mean to attract surgeons from all over Vienna to watch? Didn't you just say that just cutting off a little thing is so attractive? "

"From the perspective of the operation itself, it is only to cut off the protruding nucleus pulposus, and if necessary, the lamina needs to be removed." Carvey explained, "However, no one has done this kind of operation, so when the time comes There will be a lot of people who want to see it up close."

"No one did it. No one did it???"

The world's first surgery for lumbar disc herniation appeared in the 40s and 70s, and it is still [-] years away.It's also due to the fact that the old marshal doesn't understand medical treatment. If Ignatz or Watman were to stand aside, I'm afraid he would have felt something was wrong.

They have never heard of lumbar intervertebral discs, L, S, or nerve root compression.

Carvey's age and the uniqueness of the operation surprised the old marshal, and at the same time interfered with his decision.He needs to make further judgments on the difficulty of the operation, in other words, he needs to think again.

According to Ludwig's walking appearance and the degree of pain in his waist and legs, he might let go after a few days.Moreover, the operation was also a good opportunity for him to escape the war. One operation could allow him to rest in bed for half a year, perfectly avoiding the scheduled fighting time between Prussia and Austria.

So Carvey knew very well that no matter what the outcome was, as long as he had an 80% success rate in his hand, the old marshal would definitely agree to the operation.

Now the problem is back to Karvey himself. He is not proficient in this operation, and it really needs some practice. This is the first time that Karvey urgently wants to dissect a dead body after traveling to Vienna.

Fortunately, the spine is different from the internal organs of the abdominal cavity. Even if the corpse is stored for a longer period of time, it will not be a serious problem. As long as the bones are not damaged, it can simulate the appearance of the operation.

Before he can devote himself to practicing surgery, Carvey has one more thing to settle.

The carriage that carried him away from the manor didn't return to the Municipal General Hospital, but instead went around the Ring Road and headed southeast to Graze Hospital.

The second half of the peasant woman's operation yesterday was done by Kawei, and in his eyes, this was already considered his own patient.Since he is his own patient, Kavey must understand the postoperative recovery situation, even if he does not live in the Municipal General Hospital.

The maternity ward of Graze Hospital is not much higher than that of the Municipal General Hospital, and it is full of pregnant women who are about to give birth or have already given birth.

The cries of the baby come and go, and it is already very noisy to hear it once in a while. Living here for a long time is simply torture.

But compared to the dirty and crowded environment of the Municipal General Hospital, Graze Hospital charged higher hospitalization fees. At least the environment was fairly spacious, and there were not so many rats. There were even curtains around the beds to ensure the privacy of the patients. .

The peasant woman lives near the gate.

As soon as Carvey entered the door, he saw Dr. Olgi pressing her stomach, and soon a soft whine came from her ear: "Hold it, it will be fine soon."

"Ms. Olgi."

"Huh? Carvey, why do you come here when you have time?" Orgi pressed back and forth on his stomach several times according to Carvey's post-cesarean care requirements, "This is for your own good, so that It can clear the dirty things in the stomach."

Carvey had judged that the peasant woman had chronic gynecological inflammation, and it was the protracted inflammation that led to the adhesion of the tissues around the pelvic cavity.

Adhesions hindered the operation process, and even almost killed her, and after the operation, it would further affect the recovery of the incision after the operation.Before the final incision was sutured, Carvey asked Olgi to take off the rubber tube of the infusion bottle, cut a few small holes in the tube and put them into the incision for continuous drainage.

Although the rubber tube is not as strong as the metal drainage tube, it can be well hidden under the skin of the abdominal cavity. 【5】

If there is leakage from the incision, it will flow out through this rubber negative pressure drainage tube to ensure that the inside of the incision is dry enough.

However, even with sufficient preparations, modern medical treatment still has nothing to do with the microorganisms that reproduce in the body, and Kavey came here to see if there is anything that needs his help.Because in his experience, peasant women are always infected anyway, it's just a matter of severity.

"How's her wound going? How fluid is it draining?"

"The incision is well made." Olgi was in a good mood. "There is not much fluid drained out. If there is no accident, the tube is going to be pulled out today."

"Looks good?"

Carvey didn't quite believe that the aseptic environment during the operation was so bad, the operation time was delayed to an hour and a half, the peasant woman had chronic infection in her body, and there was too much blood loss during the operation.It stands to reason that the incision can ensure that the thread does not collapse, and the amount of drainage fluid is not too much, which is already blessed by God.

No matter how you think about it, it shouldn't be "good looking".

But when Olgi lifted the gauze covering the incision, what Carvey saw was indeed a dry and well-sutured incision.The sutures were tightly closed, and there was no leakage from the pinhole, and there was no seepage of liquid in the drainage bottle on the side.

Carvey had had quite a few cesarean sections, and this had to be the best post-op incision he'd seen so far.

　This chapter is a bit messy today, wait for me to take a shower and sort it out slowly

　　
　
(End of this chapter)