Nineteenth Century Medical Guide

Chapter 197. 194. Surgical plan of continuous reversal

[I saw that many book friends wrote about liver flukes. Liver flukes are completely different from schistosomiasis. For details, you can go to the previous book for a detailed introduction, so I won’t go into details here]

The prevention and control of parasites in China has been very strong, and it can be said that schistosomiasis has been basically eliminated.Although there are still sporadic infections, and more of them are imported cases returning to China, it is true that Carvey has not encountered schistosomal cirrhosis for a long time.

Scarcity is one thing, diagnosis is another.

There are endless inspection methods in modern times, and a single B-ultrasound of the liver can make schistosomal cirrhosis invisible [1].Moreover, early bloody stools and anemia will also make clinicians more vigilant, and the diagnosis can be confirmed by fecal examination of insect eggs and history of contact with infected water.

It may be that domestic prevention of schistosomiasis is too good. Carvey, who has been working in a big city, seems to have forgotten the various schistosomiasis cirrhosis he has encountered, and is not aware of the diagnosis of this little thing.

Now recall the main points of schistosomal cirrhosis, one of the important ones is that there are few nodules, and only some fibrous hyperplasia is generated on the liver capsule, so simple direct vision is prone to deviation.

The mainstream schistosomes are divided into Schistosoma japonicum, Schistosoma mansoni and Schistosoma haematobium, with similar life histories [2], but there are some deviations in the requirements for the living environment after entering the body.

Most of them will gather around the portal vein, adsorb on the blood vessels, continue to suck blood, grow and develop until they grow into adults, and then leave this area to find their own parasitic position.Once the amount in the portal venous system reaches a certain level, obstruction will occur, so there will be portal hypertension, giant spleen, upper gastrointestinal bleeding and ascites.

Now it is meaningless to talk about the history of tourism and the history of contact with infected water. It is also meaningless to talk about the type of schistosomiasis, whether it is Schistosoma japonicum, Mansoni, or Schistosoma haematobium.

Because the black adult worms in the mesenteric vessels are telling enough.

There is no room for surgical treatment of schistosomal cirrhosis at this stage, and the dissection of a single porta hepatis can kill surgeons.What Carvey can do now is to improve Fernan's upper gastrointestinal bleeding as much as possible, or at least stop the bleeding.

The operation returned to the previously envisaged giant splenectomy + splenorenal shunt.

Although he returned to the original surgical plan after a long detour, the clarification of the cause gave Kavey confidence, and he was willing to add something else to the original plan.

But before that, he had to let the audience know about this, and he also needed to make a subjective modification to Fernand's medical history stated earlier: "The prisoner's body seems to be parasitized by some kind of insect, which can be found in the mesentery. See them in your veins."

"It looks like a very small nematode." Herman leaned forward and took a closer look and said, "I remember a German doctor who went to Egypt mentioned a nematode a few years ago, about the size of this one."

Nematodes found in Egypt?

That is basically Schistosoma haematobium did not escape.

Carvey asked, "Do you know the name of that nematode?"

"It seems to be named after the doctor, called Schistosoma."

This is a very old name. Because of the difficulty in obtaining Western books, it has been active in the domestic parasite control manuals in the 70s and 3s. It was not until later that its scientific name was slowly changed to Schistosoma. 【[-]】

Carvey breathed a sigh of relief. Now that someone has confirmed the bug, it is easy to explain: "The bug exists in his various blood vessels, blocking the blood flow, so it causes hypersplenism and enlargement, and also makes the The surface of the liver is rough as if wrapped in linen."

The audience, who were not very interested in surgery before, began to narrow their eyes and looked at the mesenteric blood vessel in Carvey's hand.

The exciting thing of bugs getting into the human body, they naturally hope to have a good look at it.It is a pity that even if the telescope magnification is adjusted to the highest level, only some intestinal segments and mesentery can still be seen, and there is really nothing that can be done about the blood vessels in the mesentery.

"It's the first time I've seen this happen."

"Can insects do this kind of thing? It's so strange!"

"I can't see it, I can't see it at all!!!"

"Only after the operation is over, see if I can take two pieces from him to watch."

Where there is praise, there will be belittling, especially when facing Carvey, some people's jealousy and competitiveness will go into full swing: "This diagnosis is too hasty, and I have never heard that parasites can enter Vascular."

"It looks like a bit of a grandstanding game."

"Anyway, the abdomen will be closed immediately after the operation. He may not open the blood vessels to take out the worms one by one. Without evidence, there is reason to doubt the authenticity. If everyone follows his example, how can surgery develop?"

Of course, Carvey's operation would not be able to remove the worm, even if he had a whole set of microsurgical instruments, he would not do it.

Because even if all the bugs visible to the naked eye are removed subjectively, it is still impossible to determine whether there will be bugs left in other places.Bugs are just like cancer, as long as one is missed, it will not take long for it to transform into thousands of offspring.

To deal with schistosomiasis, we must honestly and practically deal with schistosomiasis, praziquantel.

It is a pity that praziquantel is a synthetic drug, and it certainly did not exist in the 19th century.In addition to the most basic medical supportive treatment provided by Carvey with adrenal gland + pituitary extract, surgery is a good way to effectively prolong the patient's life.

Modern surgery does not have much overlap with portal hypertension and esophageal and gastric varices. It is more often left to the endoscopy room for endoscopic hemostasis + sclerotherapy + ligation, or to the interventional room for vascular embolization and devascularization.

Spleenectomy is a difficult surgical method for modern medical treatment, and it has basically been eliminated as an indication for surgery.The splenorenal shunt has gradually withdrawn from the stage of history due to difficulty and complications.

But in the 19th century, this whole set of surgical methods to deal with portal hypertension appeared to be extremely advanced.

It is so advanced that it feels like watching a sci-fi movie.

At this time, Herman, who knew a little about Schistosoma haematobium, reminded Carvey: "I still remember the doctor's description at the time, 'the bladder of a patient with long-term hematuria was actually filled with gray-white worms'. Creepy."

Schistosoma haematobium prefers the bladder after the portal vein matures, and indeed likes to cluster in the bladder.Mansoni, on the other hand, like Schistosoma japonicum, prefers intestinal blood vessels.

However, no matter what kind of schistosomiasis it is, its larvae and eggs like to burrow randomly. Now combined with Fernand's bizarre medical history, it is not difficult to see the role played by larvae and eggs.

Bladder stones are the first to appear.

Although the incidence of bladder stones is very high without antibacterial measures, there is still a high probability that Fernand's bladder stones are caused by the accumulation of worm eggs.If you don't have the habit of smashing and checking, it is easy to miss this cause.

The second is breast hyperplasia.

One thing that has always surprised Carvey is the speed at which Fernand's breasts proliferate.In just a few days in the hospital, breast hyperplasia became so obvious. In addition to the role of hormones, insect eggs are also an important reason.

Carvey has experienced the era of schistosomiasis, and has seen cases of ectopic parasitism of mammary glands through spinal veins and intercostal veins.This external stimulation will cause inflammation of the mammary gland, and then pathological hyperplasia of the mammary gland, and finally even cause breast cancer.

Looking back now, it is a pity that Fernan's bilateral breast glands were not carefully cut and a large number of specimens were pathologically performed.

The last thing is the gao pill.

Fernand's gao pill cancer was based on pathological examination, but the cause of its occurrence is unknown.Just like the mammary gland, repeated stimulation of ectopic parasites by parasites is a hotbed of chronic inflammation and an important factor for canceration.

On this basis, it is impossible for Carvey to spare any organ in the abdominal cavity.

The operation has also changed from simple treatment of portal hypertension to treatment of portal hypertension + investigation of multiple intra-abdominal nodules.

General abdominal exploration has a clear sequence, starting from the liver, entering the splenic region through the esophageal hiatus, then the stomach, duodenum, biliary tract, pancreas, small intestine, appendix and ascending colon, transverse colon and omentum, descending colon, The sigmoid colon and rectum, and finally the bladder.

If you are a woman, you also need to add the inspection of the uterus and accessories.

"Don't be in a hurry to give me a scalpel, I still have to do an investigation."

Kawei rejected the knife that Damirgang brought, and put his hands into Fernand's stomach again.Because of a series of mistakes that caused a major reversal in the diagnosis before him, and the lack of inspection tools, Carvey became more and more cautious.

At the same time, I also hope that the three assistants around me will be as cautious as he is now when they are the chief surgeons in the future: "The patient has upper gastrointestinal bleeding. The possibility of peptic ulcer rupture and bleeding needs to be ruled out.”

Carvey's hand explores from the pylorus of the stomach along the large and small curvature of the stomach to the cardia. If there is an ulcer causing severe bleeding, he should be able to feel the abnormality on the surface: "Usually, at that time, the ulcer will go deep into the muscle layer, and even penetrate the entire body. The gastrointestinal wall had a special feeling of being soft and rotten with a bit of hardness."

After checking the surface of the stomach, his hand entered the back wall of the stomach from the lesser omentum sac, and he didn't withdraw it until everything was checked: "Next is the duodenum, where ulcers may also occur."

The half an hour of the operation from 1:11 p.m. to 1:40 p.m. was "wasted" by Carvey on the so-called differential diagnosis and abdominal examination.

After the investigation of gastroduodenal ulcer, there is also the investigation of egg deposition nodules.If such a strange nodule is found in the abdominal cavity, considering the influence of the size of the nodule and the degree of inflammation on the viscera, it is necessary to choose to ignore palliative care or actively perform surgical resection.

The approach to detection of abdominal masses and nodules is more complex than that of ulcers.

Ulcers are present in the GI tract, so following the anatomy of the digestive tract all the way down will end the exploration.However, the nodules and lumps produced by egg deposition or ectopic parasitism do not have such a rule to follow, and it is a carpet search without a clear target.

Remove the stomach and duodenum that have been checked just now, and the most troublesome and most likely problem is the long intestinal tract.

Schistosoma parasitizes in the mesenteric blood vessels, and the intestinal tract is the first territory they occupy when they expand outward.The second is the deep kidney, whether it is the adrenal gland or the kidney itself, once such nodules appear, there will be no good results.

So after avoiding the unexplorable hepatic portal and the gallbladder, spleen and pancreas that he had just touched, Kavi put all his focus on the lower abdomen.

For the intestinal tract, Carvey tried his best. Every segment was squeezed by his hands, and finally found a huge nodule on the position of the left descending colon.

"The location is a little ambiguous, and the volume is quite large." Carvey made a simple measurement with his fingers, "5*4*1cm, it's like a cover on the intestinal wall. If it wasn't because he had severe liver ascites , it may be touched during the physical examination."

Herman asked: "How to deal with this?"

"The volume is not small, but the degree of invasion is not bad. It protrudes more on the outside, and does not invade the intestinal mucosa much."

Carvey carefully touched the extent of its infiltration, and explained: "If it continues to grow, or the infiltration deepens, and there is a possibility of perforation of the intestinal wall, it must be surgically removed. Now we still have major surgery in hand. Let’s do it, let’s take this thing for a while.”

Herman nodded, and prepared the surgical instruments according to the previous training: "That's still to do the splenectomy according to the original plan."

Carvey said, "Wait, there's one last bit of rectum left unexamined."

"I'm already checking the rectum."

Damirgang, who was standing aside, had continued to probe downwards according to Kawei's method. While speaking, his fingertips suddenly touched a big thing.Damirgang expanded the scope of detection around, and couldn't help but darken his face: "There is something wrong with his rectum, and there seems to be a bigger nodule around it."

[Too tired, this chapter and the typo will be corrected tomorrow]

(End of this chapter)