Nineteenth Century Medical Guide

Chapter 206. 203. Warm Up
[The editor said that this chapter that I swallowed before said that it will be released in a few days, everyone should wait a little longer, otherwise it will be more troublesome to delete it all repeatedly]

The patient this time was fundamentally different from before.

Ludwig was the Marshal of the Reich, with an honorable status, and the location of the operation was on the very delicate spine, close to the central nervous system.

The operation is related to his later life, and success can heal the low back and leg pain that has lasted for ten years.But if the operation is improper, although it will not be paralyzed, it will seriously affect the stability of the spine.Some failed operations will aggravate the original pain symptoms until all sensory sensation in the area responsible for the nerve disappears, and the postoperative hematoma will also cause severe compressive pain.
These are actually surgical complications. In order to protect himself and obtain decision-making power during the operation, Carvey and Ludwig must sign a statement similar to an informed consent form.

"Mr. Housekeeper, please read carefully. It is clearly written here that 'during Mr. Ludwig von Benedeker's anesthesia, Dr. Kavi Heins is solely responsible for all related matters during the operation'."【1 】

Carvey pointed at the signature of the last old marshal: "It's written in black and white, you watched him sign it."

The butler knew about this statement, and he was indeed present in the drawing room last night.

It's just that his understanding of the statement was limited to medical aspects, and he didn't think about other aspects at all, let alone why he had to take off his pants for waist surgery.For the current head of the noble Benedek family, being stripped naked by a pariah is like putting a door of pork on a bed. It is not only indecent, but also an insult to the whole family.

"I have accompanied the master on the battlefield before, and I have suffered several wounds, and I have also suffered from a surgeon's knife. I have never seen such an operation." The butler rolled up his sleeves and lifted his shirt, revealing several scars, "If you do this, It is humiliating the Benedek family!"

"Forget it, old housekeeper, the surgery now is not as good as it was back then."

Seeing that the two men were at war, Watman ran out to smooth things over: "To be fair, Dr. Carvey's actions were all based on the marshal's health considerations. From a medical point of view, there will be no problem."

"Is it understandable that there is a problem when considered from other angles?"

"But we're operating now!"

Watman didn't know what medicine the old man had taken wrongly, why he kept staring at taking off his pants.But one thing he can be sure of is that the old butler will never do anything against Ludwig: "The ether has already worked, and we are in a hurry. The second anesthesia will be very risky. If there is any problem, wait until the operation is over." Let's discuss it again."

At this point, the butler finally gave in, but he still couldn't swallow his breath. After cursing for a while, he and the two maids took off the marshal's pants.

If it had been changed to a week ago, he would never have treated Carvey like this, and he would have treated him like any other doctor.In addition to the necessary respect, it is more about the recognition of Kawei's technical ability. After all, so many excellent doctors in the field are helping him.

To be able to perform surgery in front of so many people, the technology is definitely nothing to say.Even if there was a misunderstanding about disinfection and undressing, it was the business of Karvey and Marshal Ludwig. He had no need or qualification to stand up and make irresponsible remarks.

What really upset the housekeeper was Fernan's operation.

Fernand killed Albert who he had watched grow up, and Carvey saved Fernand, the transfer of disgust was so simple.

"If I had to choose between 'resuscitating a death row inmate' and 'showing surgical skills', my attitude towards that operation would definitely belong to the latter." Carvey explained, "If you really want to find someone to vent your anger on, I would I think we should go to Mr. Edward, the French ambassador who has not agreed to the execution so far, and those fanatical fans who send letters to the murderer every day."【2】

In a nutshell: [I am only in charge of surgery, and I don’t know anything else]
Carvey also did not expect that the results of this portal hypertension surgery have gone far beyond the scope of medicine.

The final curtain call was unsuccessful, and such a big mess not only reflected Edward's ambivalence at this time, but also reflected some people's pursuit of pure sensory stimulation.As for the affirmation of medical progress, I am afraid it is not at all. 【3】

It's outrageous, but it's not too surprising for Carvey.

Perverts, there are all ages.

Listening to Carvey's explanation, the butler had nothing to refute, and he took care of the cushion on the operating table: "So this sure murderer got away with it like this? Just because of a Frenchman? Just because of those letters ?”

Carvey didn't know what Edward was hesitating about. He just felt that it was not difficult to get things done: "Just wait, the Frenchman will definitely find a way to solve all this."

housekeeper:"???"

"Okay, next we are going to disinfect the bedroom." Carvey opened the door, "You are waiting outside the door. If there is a need or the operation is over, I will tell you as soon as possible."

After solving Fernan's portal hypertension, Carvey called the chief physicians in front of him to "explore" the cause and treatment of low back and leg pain.It took him five days to convince the four people in front of him of the diagnosis of lumbar disc herniation.

Marshal pain is located on the right side, at the position of lumbar 4-sacral 1.

Modern lumbar discectomy has entered the era of minimally invasive surgery, which is synonymous with small incision, less bleeding, fast healing and fast recovery.

It's a pity that Carvey couldn't do this. He chose the most classic posterior median approach for lumbar discectomy, which was reported by Mixter and Barr in 1934 for the treatment of sciatica. It was also the first lumbar discectomy in the world. 【4】

The difficulty of the operation is not high. After all, it is a simple resection that has been carried out for decades. After a lot of optimization, as long as the procedure is followed, there will be no problems with the operation specifications.

But before the surgery, there was a troublesome problem: positioning.

The position of the vertebral body is very clear under the imaging examination, but when it comes to the operating table, there is no C-arm X-ray machine, and the doctor can only do body surface positioning.The body surface positioning of the lumbar spine is not easy. Only one of the five vertebral bodies is basically fixed, and that is the gap between L5 and L4, which is the spinous process of L5.

Fortunately, the area of ​​lumbar 4-sacral 1 for this operation is large enough, and it happens to cover this location.

"From the autopsy, we can know that the gap between the L3-L4 spinous processes is just on the line connecting the highest points of the iliac crests on both sides." Carvey made a simple measurement and selected the starting position of the knife, " We'll start here and cut down."

If it is a common lumbar disc herniation, Carvey may place the incision 1.2-1.5cm beside the spinous process instead of the midline.

However, the old marshal had obvious protrusion and his symptoms were very serious. Most of the laminae had to be removed during the operation, so he had to choose a midline incision.

"Give me the diluted adrenal gland extract." Carvey waved at Sears, took a syringe, and injected the liquid inside into the subcutaneous and paraspinal muscles, "Slowly rub it, and then cut it Opening the skin can reduce a lot of bleeding and give me a scalpel.”

The needle barrel and the blade were interchanged, and the latter directly cut open the skin of the old marshal's back waist and entered under the skin.The fascia was incised along the spinous process and the midline of the interspinous ligament, and then the paraspinal muscles on both sides were peeled off. 【5】

"Periosteal stripper." [6]

The reason why the operation has been delayed until now is that apart from Carvey needing some practice, the equipment is also an important factor for him to wait.

Intra-abdominal operations in general surgery are delicate organs, and can be done with the most basic needles, threads, forceps, and knives.But the orthopedics department is different. After the surgical area and method are changed, the instruments also need to be changed. At least the saw used for ordinary amputation cannot be used on the spine.

So Carvey wants to re-make a set of surgical instruments dedicated to modern orthopedics.

"We first peel off the paraspinal muscles from the spinous process and lamina from the subperiosteum. We should peel off the subperiosteum as much as possible to reduce the damage to the paraspinal muscles and avoid secondary bleeding. The peeling range includes lumbar 4 and lumbar The upper and lower half lamina of 5. From the spinous process and the lamina to the inner edge of the facet joint, the range should be extended to the outer edge of the lamina to avoid damage to the articular process and joint capsule.”【7】

Carvey held the peeler in his hand and slowly peeled off the muscles on the bones: "The order needs to be in the order of waist 4, waist 5, and then the inner side of the articular process of waist 4."【8】

The peeling of the periosteum took some time, but that time allowed Watman to ask questions about the procedure.His focus is on the feasibility of surgery, because at this point in time, no one has linked sciatica to Virchow's tumor. 【9】

"Professor Weilshaw's understanding of bones is biased. This is not a tumor, but a rupture of soft tissue called an intervertebral disc."【10】

Carvey explained: "And its protruding happened to press on the nerve, so sciatica appeared, right, I remember that Dr. Lassegue in France had discovered the relationship. If I remember correctly, he should Only relevant papers have been published.” [11]

"Dr. Ruthger?" Waterman frowned. "Is that in his thesis?"

Olgi and Massimov stood by the operating table, shaking their heads: "Don't talk about papers, I haven't even heard of this person's name."

"Should be a very low-key doctor."

In fact, Carvey is not sure whether it has been published. There are too many and complicated papers, and various medical journals receive hundreds of manuscripts every day.But what he can be sure of is that Rasseger is the inventor of the straight leg raising test, and he has been using this test since a long time ago: "It was only by Dr. Rasseger's examination that I was able to clarify the condition of the old marshal."

"Oh, so that's the case." Watman also considered the major journals, but he didn't expect that he would miss this important discovery. "I'll talk to him after the operation is over."

"Then I have to go and see."

"Okay, let's go together."

kindness? ? ?
This time I can't make it up to Carvey: "Are you going to Paris together?"

"Why are you going to Paris? He lives in the embassy and is the temporary medical consultant of the French ambassador Edward." Watman said, "I heard that he will stay in Vienna for three months, so he probably came here to relax. By the way, he You sat beside Edward to watch your operation before, don’t you know him?”

Is that man Russeger?
Carvey was a little confused, but the movement was still driven by muscle memory to peel off the periosteum: "Oh, I really don't know it. I didn't expect that it was Mr. Rasseg. I just heard his name and special inspection methods. Never seen a real person."

Very far-fetched explanation, but common in the 19th century.Photography is not popular, and it is difficult to record all facial features in portraits, and the traffic is so inconvenient. It is not easy to know someone and remember someone. The situation mentioned by Carvey happens all the time.

"Then let's go together after the operation is over."

"By the way, I will also bring the operation process, so that this French doctor can see the Austrian operation method."

"Ern, okay." Carvey has no reason not to go, so he can only agree.

It's a lot of lying, but it's not impossible, it's nothing more than pushing it on some unknown adoptive father doctor.What he thinks now is not how to lie, but how to do this operation well: "Give me wet gauze."【12】

Hills has been watching the operation and is very interested in the periosteum stripping. He handed the gauze and asked, "What will happen if this layer of periosteum is not stripped?"

"There will be a lot of bleeding, and the subsequent laminectomy will be difficult." Carvey said, "This is actually the same as the separation of the anatomical structure in abdominal surgery. If you don't separate it, you can't see it clearly. If you can't see it, you can't do anything Do the cutting, if you force the cutting, it is easy to make mistakes."

During the conversation, Carvey had already peeled off the periosteum around the lamina together with the muscles: "Give me the retractor."【13】

The appearance of the retractor has greatly reduced the workload of Olgi and Massimov. Both of them are old, and it takes a lot of energy to pull the hook: "This is really a good invention, freeing your hands. People are old After that, it’s really useless to do anything.”

Massimov also shook his sore shoulders, and had no choice but to accept: "Oh, my shoulder is really getting more and more unbearable."

Both of them disliked themselves for being old, but their eyes were fixed on the incision opened by the retractor, wanting to see Kawei's next operation as soon as possible.

The retractor not only retracts the skin and subcutaneous tissue, but also needs to push away the paraspinal muscles together to completely expose the vertebral lamina below.At this point, the operation begins to get rid of the warm-up stage: "The following is the ligamentum flavum between the vertebral bodies. We need to remove the ligamentum flavum and completely enter the space between the vertebral bodies."

The four of them accepted the call, and the room fell silent instantly.

They have experienced the autopsy and the training of Carvey, knowing that the operation has officially entered the difficult area.

Nerve roots and joint capsules can be seen below the ligamentum flavum, and a little carelessness in the operation would leave irreparable damage to the central nervous system of the old marshal.

Carvi compared the cutting area and said: "Let's hurry up and give me the osteotome and rongeur. Before dealing with the yellow ligament, we must first break the upper lamina."【14】

[This chapter of 4000 text + 2000 is considered a big chapter]

(End of this chapter)