Nineteenth Century Medical Guide

Chapter 165
From the beginning of more reliable surgical operations in the 18th century to 1866, where Carvey is now, the treatment of breast cancer has undergone total mastectomy, total mastectomy + dissection of lymph node involvement, and combined total breast + armpit tissue resection. The question since then is how to cut and how much to cut.

Because of the high recurrence rate of breast cancer, doctors can only expand the scope of resection as much as possible.This practice of preferring not to let go is indeed effective. The recurrence rate of surgical treatment for early and mid-stage tumors was once lower than 10%, which also established the status of radical mastectomy in breast cancer resection. 【1】

It has to be said that Austria's understanding of breast cancer surgery at that time was always at the second- and third-rate level.

As early as 1852, the United States had the concept of lymph node dissection, and now German doctors have given the theoretical basis for lymphatic metastasis, but so many Austrian doctors, including the dean of the Academy of Surgery, are still skeptical about axillary lymph node dissection.

To enlighten his colleagues, Carvey chose a staining method based on the sentinel lymph node biopsy technique commonly used in modern breast cancer. 【2】

He believes that the Austrians, who are extremely obsessed with art, will naturally believe in the relationship between lymph and breast tumors after seeing such a picture similar to a blue star map.

"My injection points are subcutaneous, adjacent to the tumor, and subcutaneous, and now there is a map of lymphatic channels." Kawei and Damirgang pulled the skin outward together, revealing a blue channel, "We The concept of sentinel lymph nodes needs to be introduced here."

After finishing speaking, according to the content of the preoperative rehearsal, the nurse opened a black curtain beside the wall, revealing a large blackboard behind it, on which was the affiliation diagram of lymph nodes from near to far that Kavey had drawn before. 【3】

"We can clearly see that lymph node metastasis is just like railway transportation. The tumor will first enter the first station from the cancer tissue through the lymphatic vessels, which is the sentinel lymph node that Mr. Watman and I just mentioned. After entering the sentinel lymph node, they Then move outward step by step.”

Carvey buried himself in helping Watman separate the subcutaneous fat, and said: "From this simple grid diagram, it can be seen that any distant lymphatic metastasis must pass through the sentinel lymph nodes, and 'jumping' cannot occur."

In the eyes of ordinary people, this seems to be very easy to understand.

But in the eyes of 200 surgeons, before Carvey said this, many people thought that the metastasis of the tumor was jumping.Even many people do not have the concept of lymphatic metastasis, so that they think that tumor metastasis is the recurrence of a new tumor.

"Our principles are"

"Dr. Carvey! Wait!!!"

The sentence just now is a bit of a mouthful, but it is so important that many people have no time to write down the whole content: "Just now you said that any lymph node 'metastasis' is what we have been talking about before. 'Palpable lymph node swelling ’, must go through the sentinel lymph node first?”

This is a good question.

The main focus is on "palpable lymph node swelling".

"So, does the unpalpable swelling mean that the lymph nodes have not metastasized?"

Carvey raised his head and looked at the voice that asked the question just now: "If there is sentinel lymph node metastasis, we will do the dissection, and if there is no we will not do it. In this way, many tumor recurrences caused by misjudgments or excessive damage to surrounding tissues can be avoided. resection."

It used to be the concept of sentinel lymph node, but now it is the meaning of sentinel lymph node biopsy.

In just 10 minutes, Carvey completed a teaching of a new knowledge point:
"Because all the surgeons here are capable of acting on their own, I try to be as concise as possible in describing the sentinel lymph nodes. In principle, the resection is strictly based on the results of the rapid pathological examination of the sentinel lymph nodes, which requires my teacher: Professor Ignatz, and two pathology assistants to Dean Waterman: Dr. Bergt Von Celestin and Dr. Robert Koch."

Pathology was originally a discipline that assists surgery in judging tissue types. Inspections are often performed after surgery and are only responsible for the final diagnosis and have no guiding significance for the surgical process.No matter how you look at it, it is a discipline that is more theoretical and the research content is quite marginal.

Who would have thought that a surgery presided over by a chief of surgery would require pathological examination to determine the extent of the surgery.

Fortunately, the lineup of doctors for pathological examination is luxurious, and Ignaz is the strongest surgeon in Austria. The urology, intestinal surgery, and orthopedic surgery involved have already achieved the first place in terms of operation speed and postoperative survival rate. .

It was outrageous but reasonable to let him do the pathological biopsy beside him. Who told him that it was his father and students on the operating table.

Behind him is the son of the Viscount Clichy of the House of Lords. He has just graduated from medical school and is still very young. He is also a student of Ignatz in name and has a bright future.

But who is Robert Koch at the end?
Why never heard of it.

"Koch. Such a familiar name." Edinson thought of the conversation he had with Professor Langer from the Anatomy Department when he went to the Medical School of the University of Vienna. "I remember it as a German who just came to Vienna."

"A new German?"

"When did you come?"

"Looks great."

"To be able to do the pathological examination on the same stage as Dr. Ignatz."

These words almost came out of the mouths of the four people around him at the same time. Eddinson explained: "He is a German medical doctor who has not yet graduated. I heard that he came here for a study tour, and he has to go back when the time is over. "

Edward thought that the two places were already at war: "At this time, there are still Germans willing to come to Vienna?"

Franz said helplessly: "After all, I haven't torn my face, some activities have to continue."

"It seems that he is just a small person. Otherwise, why would Prussia let him come?" Edward seemed to have found the "weapon" to hurt the Austrian emperor again: "A small person from Germany actually became the pathology consultant of the chief of surgery in Vienna. Too."

As a diplomatic ambassador, he should not have competed with Franz everywhere.

But before the French-Austrian War, France won too thoroughly, and now the Austrian war is about to start, and it is asking for itself, which gave Edward considerable courage.But he was in Vienna after all, so he didn't finish his sentence, and the follow-up was nothing more than some sarcastic sentences about the withering of Austrian medical talents.

Franz's face was a bit ugly, but the Foreign Minister Karl took the sentence with a smile and mixed up: "Yes, being the pathology consultant of Dean Watman must have its extraordinary side, Prussia is too blind."

The same thing was being discussed by the two of them, but there was no conclusion in the end.

In fact, Koch at this time was a very ordinary doctor of medicine, and many hospitals in Berlin did not have a place for him to work.If it weren't for someone from the Institute of Chemistry who could help to speak up, he might have to pack up and go to the countryside to become a small doctor.

Now being sent to the highest-level surgical theater in Austria by Kawei, although he is not able to go to the operating table, doing a pathological examination with Ignatz is enough for everyone to remember his name.

The original pathological examination is usually performed by the surgeon in person, which is time-consuming and labor-intensive.

Now that Carvey has moved out of the assembly line, the dyeing has been completed, and it only needs to be transparent with xylene, sealing wax into the mold, sectioning, and microscopic examination.Although no dehydration was done, it was a quick biopsy after all, so there was no way to take that much into account.

"Here we come, sentinel lymph nodes!"

With the help of Carvey, Watman cut off a piece of fat tissue with blue dots from the side of the breast[4], threw it into the nurse's metal tray, and then sent it into Ignatz's hands: "Wait wait, there seems to be more"

Sometimes there is a single number of sentinel lymph nodes, but sometimes there are several groups of lymph nodes gathered together. The case of the countess belongs to the latter.

"Second Block"

"There is a third block"

"It should be gone."

Carvey checked back and forth, then shook his head: "It should be only these three yuan."

Watman breathed a sigh of relief: "According to the original operation plan, Dr. Carvey and I will first remove the countess's breast tissue, and wait for the results of the pathological examination of the sentinel lymph node before we decide whether to remove her armpit. "

So far, the operation team has been divided into two groups. One group performs sectioning by Ignatz group, and the other group relies on Watman and Carvey to perform mastectomy together.

The name of the operation seems to only have the word "resection", but behind it is "radical cure".

Furthermore, the mammary gland is different from ordinary amputation. It is a three-dimensional multilayered structure including skin, fat, glands, fascia, muscles and various blood vessels and lymph.

To be honest, Watman is not good at breast cancer resection, and he has done it on very few patients. It can be said that in the past three days, he has supplemented the breast structure, blood supply and lymphatic return, and has a systematic and comprehensive understanding of them. 【5】

In addition to being familiar with various knowledge points, Watman also deliberately made further improvements to the original operating table that could be bent back and forth.

Now the operating table in front of them was tilting to the left, exposing Giustina's entire right breast and underarm structure, and reducing the operating distance of the assistant on the other side.

Considering Justina's high requirements for postoperative quality of life, the surgical incision was an oblique fusiform incision.Starting from the front of the armpit on the upper side, and the inner side of the lower costal arch, this type of incision can reduce the impact of scars on upper limb activities. 【6】

The skin had already been cut when the sentinel lymph node was removed, and Wattman now needed to further peel off the inner flap of the incision.

Damirgang and Amor each took four tissue forceps, clamped the edge of the skin and lifted it up to do reverse confrontation, exposing the innermost cutting surface.Watman used a scalpel to cut, while Carvey took suture needles and thread to suture the unstoppable blood vessel bleeding at any time. 【7】

Watman learned a lot about the main points of mastectomy from Carvey, and after several simulations on corpses, he at least achieved the effect of sharpening his gun in battle.

But Carvey's reminder is quite necessary: ​​"Now the director is using a surgical blade to cling to the skin, making a sharp peel along the superficial layer of fat tissue, so that no fat tissue remains on the upper and lower sides of the skin. In order to prevent the tumor from spreading Transfer, this high-precision peeling needs to continue to the distal end of the flap, until the terminal end can be selected to preserve fat”

"Give me the warm saline gauze." Kawei took the wet gauze from the nurse, tried the temperature, and then gently pressed it on the peeling surface with some small bleeding spots. "Generally choose the end of the peeling, up to the collarbone, Down to the upper part of the anterior layer of the rectus sheath, medial to the midline of the sternum, lateral to the anterior edge of the latissimus dorsi."

As soon as he spoke, the heads of those who looked up at the operation were all buried, and there was another sound of dense writing and recording.

"In case of small bleeding, warm saline gauze can be used to stop the bleeding, and if it is large, it can be directly stitched. As long as the separation level is well grasped like Dean Watman, the bleeding will not be too much."

The peeling of the skin flap was successfully completed, followed by the excision of the muscle.

Carvey did not want to undergo early radical mastectomy, because cutting off the major and minor muscles of the pectoralis would affect the function of the upper limbs, and the daily life of the countess would inevitably be affected after the operation.But in the 19th century when there was no chemoradiotherapy, he did not dare to assert that improved radical surgery could completely solve the recurrence of breast cancer, and the only thing he could do after thinking about it was radical surgery. 【8】

"Next we cut the Countess's pectoralis major."

According to previous practice, Watman first separated the cephalic vein in the deltoid pectoralis major groove, revealing the entire cephalic vein.Then, the fat tissue on the surface of the pectoralis major was separated downward to reveal the outer edge of the pectoralis major, and the Kawi on the other side was separated upward to reveal the insertion point.

The two men bluntly separated the deep surface of the pectoralis major muscle with their index fingers, preparing to separate the pectoralis major muscle and the cephalic vein along the direction of fiber running, and then they can cut at the position close to the tendon. 【9】

However, just as Watman's scalpel blade was attached to the surface of the muscle and was about to exert force downward, the vascular forceps in Carvey's hand suddenly moved forward to block the handle of the knife.

Watman knew very well that Carvey must have a purpose in doing this, and he was also shocked, his arm muscles contracted for a while, and he withdrew all the strength to prepare for the knife: "What's wrong?"

"Wait, there seems to be a blood vessel here." Carvey removed the blade and the vascular forceps in his hand, and gently stirred his fingers inward, and it seemed to poke a piece of soft tissue next to the cephalic vein, "This is too cunning, It actually runs on the inside of the cephalic vein, close to the attachment of the tendon to the clavicle.”

Watman didn't feel anything a second ago, and everything had already been trained in muscle memory on the corpse.But in the next second, his forehead was covered with beads of sweat, and he was only short of a knife. If the knife was removed, the mastectomy would probably become a death rescue.

"This is."

"It's the mutated thoracoacromial artery and vein." Carvey smiled and breathed a sigh of relief, and then took the forceps from the nurse at the side, "It's okay, it's not a particularly large blood vessel, it just needs to be separated, ligated, and cut off." , and then cut along the inner side of the pectoralis major muscle as planned.”【10】

(End of this chapter)