Nineteenth Century Medical Guide

Chapter 338 334. Surgery is More Than Cutting
Tuberculosis in modern China can often obtain effective anti-tuberculosis treatment in the middle and early stages, and the chance of developing hemoptysis is not high. Even if it occurs, it is a small amount of hemoptysis. It is not difficult to control and the risk is not high.

The reason for this is not that patients have a rich understanding of tuberculosis, nor that they have a stronger awareness of prevention, but mainly because domestic anti-tuberculosis treatment is free.

Of course, there is a limit to free, and the choice of drugs must be basic, and there is no way to waive many inspections.

Under such a policy, the chance of developing severe hemoptysis is not high.

Of course, there are no absolutes in clinical practice. If you really encounter this kind of patient, there are more ways to deal with it than in the crude 19th century.Generally, internal medicine is often used first, and hemostatic drugs are used for conservative treatment. Unless conservative treatment is really ineffective, surgery will be chosen.

The operation of modern surgery has long been out of the era of drastic measures, especially in places like the thoracic cavity, which are related to blood vessel rupture, and the use of vascular intervention and endoscopy is the mainstream.

It’s not just that doctors are showing off their skills or using more expensive medical devices to increase their income. The main thing is to consider the trauma caused by the operation and the postoperative recovery effect. After all, surgery is only to fight hemoptysis, and there is no way to really solve tuberculosis.

Carvey is living in an era where there is not even a smattering of knowledge about tuberculosis, except for some unscientific empirical methods.Patients are often seriously ill, but surgery can have a good effect.

However, limited by equipment and first-aid medicines, what Carvey can do is only the old-fashioned surgery that appeared in the 20s and 60s of the [-]th century.

Fortunately, this kind of surgery is not difficult to operate, and the effect is not bad. Even those patients with poor results are better than a few internal medicine.What's more, Kavey still has pituitary gland extract in his hand, which can somewhat stop bleeding.

The golf ball is the key to this kind of surgery. In fact, if table tennis has not yet risen, it would be better for the ribs and mediastinum to choose elastic table tennis.

There is a golf course not far from the main palace hospital, which is small in size, but it is the property of the Debord Club, the earliest golf club in France and even in Europe.Those who can enjoy here are the elites of the high society in Paris, Professor Cedieu is one of them, as well as the dean of the main palace hospital and several famous internal medicine doctors.

In the half hour after Sneijder decided to trust Carvey, ten golf balls were gathered in and out of the hospital.

At this time, we should thank the evil capitalism for evolving the original lacquered leather ball into a gutta-percha rubber ball, which is at least much better in terms of safety and flexibility, and less irritating to the body.

"First of all, we need to make it clear that tuberculosis can cause lung inflammation, and then a considerable part of it will cause tissue necrosis, and finally form a cavity."

Carvey and several others were squatting by the sink to clean the golf balls, and at the same time explained the principle of the operation: "Whether it is inflammation, necrosis or cavity can cause hemoptysis, the difference lies in the degree. The blood vessels in the lungs are inherently thin, and there are The thorax is blocked, and direct rupture cannot achieve effective hemostasis."

"Dr. Carvey, the pituitary extract has been applied." Kallen said, "The blood clot in the throat has been cleared, and the breathing is temporarily stable."

"En." Carvey looked up at Amor, "Preparing for anesthesia, you must pay attention to his breathing, and be ready to deal with hemoptysis at any time. Also pay attention to his weight, don't give too much."

"Ok."

Carvey's explanation was only halfway through, and the people around him asked questions: "The amount of hemoptysis is not large, which is similar to the usual bloodletting therapy. The surgical wound is larger and the amount of bleeding is more. Why is it necessary to stop the bleeding?"

"Dr. Sneijder deserves to be a top student at the University of Paris. That's a good question."

At this time, Sneijder took off his black coat, only wore breeches and a shirt, and brushed the ball with Cedieu and three assistants.Although he still had a grievance about surgery in his heart, the patient stopped hemoptysis after arriving in Carvey's hands, and the effect was immediate.

"I apologize for my rudeness just now."

"I'm telling the truth, I didn't mean to tease you."

Carvey explained: "First of all, to be clear, the amount of hemoptysis is not the real amount of bleeding. What we see is only the blood that is expelled from the body, and there is a lot of stasis in the lungs that will soon form blood clots. Now It’s not bad, if he continues to let him cough up blood and doesn’t position himself properly, the patient will be suffocated to death by his own blood.”

"So, what are these balls for?"

"It's just simple compression to stop the bleeding." Carvey said, "My father tried it twice when he was practicing medicine in Lombardy. I have seen that the effect is not bad. It's just that some patients were wrapped in gauze that can absorb liquid. The fat is filled, and the lungs are squeezed to stop the bleeding."

"So that's how it is." Several doctors squatting beside the water basin nodded one after another, "Since it was effective then, it is naturally necessary to try it now."

The surgical plan proposed by Carvey was once again beyond the scope of Cedieu's imagination. After all, the first operation in history to treat hemoptysis by stuffing things into the chest cavity was still 25 years away.The option to use balls instead of other foreign objects had to wait until 1945, but at that time, plastic balls made of methacrylate were used. 【1】

"Thoracic surgery, Dr. Carvey is really brave."

"Otherwise, what should I do? The final outcome of tuberculosis and hemoptysis is not good."

Sneijder is still a typical internal medicine conservative thinking: "Now I think he is stable, can he just lie down like this?"

"It's only temporary." Carvey explained, "Dr. Sneijder should know the dangers of long-term unilateral bed rest. If there is a pressure sore, he may walk faster."

".really."

Seemingly simple hemoptysis, when it came to Kawei, it became extremely complicated, and many aspects needed to be considered.In the end, he chose surgical treatment as a last resort. The amount of hemostatic medicine was limited, and Kawei couldn't bear it if he used it for this patient for a long time.

"Dr. Carvey, the operation method is indeed very attractive, but I want to learn more about the medicine you use and this peculiar way of administering it." Sneijder has a good vision, "I think this is the most important thing in the whole treatment process." part."

"The medicine is produced by a pharmaceutical factory in Vienna called Karachi." Carvey said, "If you think the effect is good, you can choose to buy it there."

"How much is a bottle?"

"Emmm, I also forgot, it's not very expensive anyway." Carvey smiled awkwardly, and then recommended other things, "For specific use, you need to check your blood pressure. You can use the blood pressure monitor I brought. Manufactured by the Laszlo Foundry in Vienna."

"blood pressure?"

"Yes, there will be some fluctuations in blood pressure." Carvey explained, "But don't worry too much. Medicines are used to stop bleeding. Patients are often in a state of massive blood loss. Raising blood pressure is also a hedge."

"Oh, I got it."

Sneijder seemed to feel that he had learned so much that, in the process of disinfecting golf balls and surgical instruments, he described the recent discovery of tuberculosis treatment in internal medicine: "In the first half of the year, we successfully cured tuberculosis with mercury nitrate A case of lip tuberculosis."

"Mercuric nitrate is not bad, it is still effective for festering."

Carvey still agrees with this powerful medicine. The method is similar to the effect of heavy metals used in traditional Chinese medicine to lift pus and remove rot. It uses the mechanism of heavy metal salts to limit oxygen uptake by cells, and the effect is definitely good.It is only limited in use, suitable for topical administration, and needs to be controlled in dose.

But the enema that followed didn't make much sense.

"We also tried making an enema with milk, a little almond oil and the yolk of an egg with a certain amount of water. Then put creosote in it, about 50ml milk with 5g creosote, which can form 2- 3 days of diarrhea."

Sneijder spoke in great detail in an attitude of exchanging medical experience with each other, basically handing over his old background.

But in Carvey's view, the only thing that might work is creosote.It plays the role of sterilization and antisepsis, which is similar to carbolic acid, but the effect of enema on tuberculosis should be very limited.

"No, no, Dr. Carvey!" Ned was very excited, "In the past half a year, we have used this therapy on more than 20 patients with pulmonary tuberculosis combined with pleural tuberculosis and peritoneal tuberculosis."

"result?"

"The results are exciting."

"Oh???"

Carvey didn't expect this treatment to be useful. Even though creosote is a carcinogen, just like carbolic acid, he would definitely choose to suppress the white plague first.

But in fact, this is just Sneijder's wishful thinking.

Because many of the more than 20 patients who were successfully "cured" went back to normal after 3-5 months of physical conditioning and nutritional support.There may be a small amount of creosote, but more of it is due to the increase of the body's immunity and the improvement of the environment.

Moreover, the proportion of "cured" is not particularly high, only 10.The rest of the patients are either on the way to treatment, or have been out of contact or have passed away quietly.

But this ratio was good at the time, at least it can make people less desperate.

"There is no rush for medical treatment. Now that the golf balls have been cleaned, let's start the surgery."

The full name of the operation is extraperiosteal plastic ball tamponade, a technique invented abroad by Gu Kaishi, a domestic pioneer of thoracic surgery.He is one of the founders of China's heart and soul, and is also a famous connoisseur and collector of cultural relics.

It can be said that many of Carvey's temporary intentions to participate in the auction before came from his cultural influence when he was teaching.

Extraperiosteal plastic ball tamponade was a technique taught by Gu Kaishi, which was actually replaced by lobectomy at that time. Kavey still learned it, and even learned the production process of this unique hollow plastic ball.

But this operation is only a compromise to the disease, from its initial start in the 50s to the rapid decline after the glory of the 60s, and then to the tepid 80s.Compared with the rapid decline in foreign countries, the difficult domestic environment still gives this kind of surgery a certain soil for survival.

Of course, in the end, it was inevitable to be eliminated by the general trend of surgical development.

"The location of the cavity is most likely the location of the bleeding." Carvey repeatedly auscultated and determined the location of the cavity. "From the auscultation, it can be roughly judged that the lesion is located at the apex of the right lung, which should be closer to the rear. So our incision is also at the rear right. I have a scalpel."

Because the patient had just undergone hemoptysis, lying on the side would aggravate the condition, so the prone position was chosen for the operation to expose the rear right side.

"We make a posterolateral incision, and peel off the rib periosteum from top to bottom, starting from the lateral and medial sides of the first rib." Carvey has not performed this operation for many years, but he still remembers it deeply. It's not difficult, "After peeling off, stuff it when it collapses with breathing, and give me gauze."

Rapid packing of gauze reduces the lung capacity, and continues to peel off the periosteum toward the spine: "Here, we must pay attention to protecting the pleura as much as possible. If the pleura is broken, it is also necessary to quickly fill it with gauze. Especially around the spine, it must be handled carefully, so as to cause serious damage. Good compression."

The operation is basically to deal with the periosteum stripping, and then create a space structure between the rib periosteum + pleura and the ribs.Compared with the spinal surgery performed on the old marshal back then, it was much simpler, and the procedure was very simple. It was mainly a question of proficiency.

"Be careful with the dissection next to the spine, it is very close to the superior vena cava and the trachea. If too much is dissected, the filled golf ball will press against these two ducts, and instead compress the blood flow and breathing." Carvey carefully used the dissection The spoon scraped off the periosteum and said, "After finding the approximate location, cut off the intercostal muscles."

Cut off the back end of the intercostal muscles, all the involvement between the lung and the ribs was released, and the lung atrophy further increased, making room for the golf ball. 【2】

"While cutting the muscle, you need to preserve the blood vessel. Bring warm water and rinse it."

Carvey found the space between the first and second ribs and began to stuff the ball in.However, there is still a big gap between the golf ball and the plastic ball used at the beginning, the most obvious being the larger size: "Get a spreader, we need to expand the intercostal space."

As long as the ribs are pulled apart, there is no difficulty in the next step, as long as the filling force is properly adjusted according to the thickness of the pleural hyperplasia.

"Although the diameter of the golf ball is too large, considering that there is a certain degree of movement in the gap between the ribs, it is better to take some measures to prevent prolapse." Carvey briefly tried the contact surface between the ball and the ribs, and said, "Sew it up for me. Wire."

Sutures are used to bind between the two ribs to reduce the intercostal space, and then a large dose of diluted methylene blue is used for washing to prevent incision infection.

"This is a very important step, otherwise the cavity left will fester." Carvey looked at the tissue that had been dyed blue, withdrew from the position of the chief surgeon, and took off his gloves, "Rinse it twice, especially The incision should be carefully cleaned. When suturing, pay attention to the alignment of the chest wall, and pay attention to controlling the range of motion of the right upper limb after the end.”

It took less than half an hour before and after the operation, and the vital signs were stable throughout the process.Except for the patient coughing up the last mouthful of blood at Sneijder before, there was no hemoptysis.

The first successful extraperiosteal golf ball tamponade.

(End of this chapter)