Nineteenth Century Medical Guide

Chapter 377 373. Skills in God (2)

In this world, there has always been relative fairness. Family background, property, professional ability, meritorious service, social connections, etc. are all the weights that influence the balance.

Kawei is a typical example. He inherited the title indiscriminately, was extremely poor, and finally got to this point with an operation that no one can do. Morisot, Manet and Maupassant are also typical examples. Three people who were not qualified to appear here entered the surgical theater because of Cavill.

With such an excellent opportunity, Morisot and Manet immediately took out their paintbrushes and started by sketching the scene, hoping to get a desired sketch before the end of the operation.

Maupassant was not so serious. His mind and eyes were in a state of separation from the moment he got off the carriage. While being shocked by the serious scenes of the operating theater and the pomp of the aristocratic royal family, I was thinking about how to turn the previous delivery in the salon into poetry.

It wasn't until Kawei called the patient's name that he realized: "Who was he talking about just now?"

"Who is it?" Morisot was still composing the picture and was not in the mood to chat with him. "It took a lot of effort to come in. Don't affect me."

Maupassant turned to the doctor next to him and asked: "What was the name of the patient that Cavey just mentioned?"

Such an impolite and extremely unprofessional question made the other party feel disgusted, but there was nothing he could do. Based on the principle of doing more than doing less, he reluctantly answered him: "Bizet, Mr. Georges Bizet, a very excellent composer." and pianist, whose works are regularly featured in the Paris theater.”

Maupassant ignored the additional titles and introductions, thinking only of the name at the beginning, and suddenly shouted: "Isn't he the guy who played the piano and sang the aria from the opera "La Juive" yesterday in Place Pigalle?"

"'La Juive'?"

Exposure to the gazes of a large number of strangers at the same time was far beyond the scope of her social skills. In order to calm her inner anxiety, she could only devote herself to the drawing. This kind of embarrassment even made her feel that although the young man was annoying, he did her a big favor by attracting everyone's attention.

In fact, after his rebirth, Kawei rarely asked questions during operations.

Pulling the muscles evenly to both sides, you can see the thyroid isthmus covering the question again, covering which tracheal ring? "

After a period of tempering, probably on the front line of the Austro-Prussian War, Hermann was finally able to keep up with some progress, followed by Damirgaon and Berget. It was a pity that the operation was immersed in the haze of war at the time, and he had no interest or time to ask questions.

But in fact, there were not many doctors in the surgical community in the 19th century who really cared about the detailed anatomy. The neck is one of the restricted areas for surgery, and few people really answer the question. Even Cedillo, who had done enough homework in advance, accidentally missed the pretracheal fascia.

Of course, this was just a small episode during Kawei's surgery and did not bring anything substantial to the surgery or the doctors present. But when time went back a few years, when Maupassant followed the advice of Teacher Bouye, when he waited for Flaubert, the "light" in his life, Bizet's incident became a plot in the novel. 【1】

"Second to fourth quarters." Begert answered quickly.

Kawei must have also been a big help.

"It should be an opera written by Flomentar Allévi 30 years ago."

Doctors all around turned to look at this bastard, and he talked about the interesting things last night as if nothing happened: "At that time, he was very interested in ordering an 'exotic' woman whose name was the same as The heroine in that opera is exactly the same! What’s her name?”

Kawi is not interested in these off-site contents. He brings them here in the hope that future great artists will gain something here.

Some doctors who were familiar with the opera chatted with each other for a few words, and everyone recalled the lyrics. Some people even couldn't help but hummed: "Rachel who comes from God, should come from God!"

The question he asked shortly after the opening instantly drew everyone's attention. His calm expression amidst the burning eyes of millions of people was in contrast to Maupassant's expression as if he was watching a play. Gazes, questions and comparisons were packaged up by Morisot and cleverly translated into a huge oil painting two years later. This work was successfully selected into the official Salon the next year. 【2】

"Anatomy is the basis of surgery. The anatomical structure determines the surgical method. You still need to work hard." Kawei put his hands on his chest, looked at Herman's progress, and continued, "Dr. Herman has already cut open the neck. Deep fascia, and then, as Professor Cediyo said just now, use vascular forceps to separate the sternohyoid muscle and sternothyroid muscle on both sides. [3]

First, too much knowledge was exposed, and it was difficult for him to explain the source of it. Secondly, it is difficult to define personal positioning, and it is also a sign of respect for the current doctors. Thirdly, the questions that can be answered often have little to do with the surgical procedures. No one can answer what I really want to ask, so I won't ask.

"Oh, I remembered, that woman's name is Rachel."

The question is not difficult, and anyone who has some knowledge of the structure of the neck can answer it.

Now that he is in Paris, the tour seems to have helped him regain some of his original feelings, and asking questions has become the product of the interaction between emotions and the surgical process.

Compared to Maupassant's familiarity, Morisot, who was sketching while standing in the crowd, looked very cramped.

As a painter, she naturally prefers to stand outside the canvas and complete her paintings in a non-disturbing manner. But she, a woman, will inevitably become the focus of a group of men in a place full of men.

Just like other directors, once the answer is correct, Kawei's next question comes: "What about the lateral lobe?"

Bergert continued to answer: "The lower edge is at the sixth tracheal ring, and the upper edge is at the thyroid cartilage."

"good."

The answer wasn't perfect, but it flipped the switch. Kawei stepped forward and took a look at Bizet's thyroid gland, and questions began to pour out like a tide: "Now that the muscles have been stretched, how do you think we should deal with Mr. Bizet's thyroid isthmus?"

Berget was a little naive and didn't realize the trap: "Pull the isthmus upward to expose the trachea." "What about before pulling?"

"Before?"

After a moment of silence, Damirgang spoke: "The lower edge should be separated, otherwise the subthyroidal blood vessels will be severed." [4]

Unexpectedly, before he finished speaking, Herman picked up the tissue forceps and began to fully separate the isthmus, and asked Karen to prepare a scalpel and sutures. The intention is obvious. Simply separating the lower edge and retracting it cannot solve Bizet's thyroid isthmus.

"Everyone must pay attention when performing tracheotomy in the future. If the patient's thyroid isthmus is too wide, do not bother to pull it. Cut it off and suture it directly to fully expose the trachea." [5]

Herman's speed is not slow, and Damirgaon's stitching skills are also quite good. After the treatment of the isthmus was completed, Bergt immediately took the syringe handed over by Karen and inserted it into the trachea. 【6】

"Before tracheotomy, use a hollow needle to puncture. If the air can be extracted, it can be determined to be the trachea." Kawei continued to explain, "After the location is clear, use the scalpel to open two tracheal rings from bottom to top along the midline. Pay attention to Dr. Hermann’s technique here. The tip of the knife must not be inserted too deep to avoid injuring the posterior wall of the trachea.”[2]

Achieving this step can basically declare that the tracheotomy is more than half successful. Kawei's explanation speed began to slow down and he focused more on the questions: "The question is again, why is the second position chosen for tracheotomy When it comes to the fourth tracheal ring, why not cut the first ring, and why not cut the fifth ring, but it cannot get through the thyroid isthmus at this position? "

The difficulty of the problem has gone up a notch, it is more troublesome than the simple anatomy. This is exactly the question of doctors who are still troubled by tracheostomy.

"The position cannot be moved downward because it is very close to the brachiocephalic trunk and brachiocephalic vein. If you are not careful, you will accidentally injure two important blood vessels." Seeing that no one could answer, Herman found someone who could answer. "As for the first ring, I'm not sure." [8]

"The reason for not touching the first ring is to avoid causing postoperative laryngeal stenosis." Kawei was quite pleased, "Let's put the cannula in."

"Ah."

Hermann used curved forceps to open the tracheal incision, inserted the tracheal cannula with stylet into the trachea, and then pulled out the stylet: "Gauze."

The purpose of the gauze is to absorb unnecessary secretions, and then put a corner of it on the cannula opening. When you see the gauze swinging up and down with the airflow, you feel relieved and say, "Give me the inner tube." [9]

After the inner tube was inserted, Hermann gave up his seat to Bergt, and Damirgaon and Bergt handled the fixing work together. The former mainly performs simple skin sutures, usually only the upper incision is sutured. If the incision is not large, it does not need to be sutured. The latter uses gauze pads to fill the gaps around the sleeve, and then uses two gauze tapes to fix the sleeve in the center of the neck. 【10】

At this point, a complete tracheotomy is completed.

In fact, Kawei was originally responsible for the tracheotomy. He first asked Herman to cut the skin and do simple separation work. After he washed his hands, he would take over on stage.

But who knows what Cediyo said changed his plan.

Leaving it entirely in the hands of Hermann significantly slowed down the process by providing detailed explanations and even filling in a lot of questions without interrupting the surgical process. With these explanations and questions, Paris surgeons’ doubts about tracheostomy can be basically solved. 【11】

The tracheotomy was completed, and Kawi and Cediyo officially took the stage.

Laryngeal cancer surgery is not that simple even in modern times. Before the operation begins, Kawi briefly describes the classification of laryngeal cancer and the available surgical procedures: "According to my observation, laryngeal cancer is divided into supraglottic, vocal cord, and subglottic cancer.

They are bounded by the vocal cords and have different symptoms. Through several previous laryngoscopy examinations, we found that Mr. Bizet’s laryngeal mass was in the epiglottis, which did not affect the movement of the vocal cords, that is, above the glottis, so what I will do today is a partial supraglottic laryngectomy. "

After clarifying the location of the operation, Kawei began to look for the location for the incision: "We choose the top of the cricothyroid membrane and make a small transverse U-shaped incision. [12]

After incising the skin and subcutaneous fat, first find the bilateral sternocleidomastoid muscles, then separate the skin along the deep surface of the platysma muscle, and cover the skin flap with moist gauze. If you have swollen lymph nodes, you can try to clean them out. Then.

In order to ensure the surgical field of view, the body of the hyoid bone must be cut off first, and the upper and lower muscles of the hyoid bone should be cut off at the upper and lower edges of the hyoid bone. Then, retractors are used to pull the hyoid bone to both sides, and then the strap muscles are separated downward. "【13】

While doing the muscle separation, Kawei had already mentioned the next step. In order to shorten the operation time and reduce the risk, he decided to skip this step and directly incise the adventitia:

"Here, we can further dissect and find the superior laryngeal artery. The location is generally about 0.5cm inside the upper corner of the thyroid cartilage. By slowly separating the thyroglossal membrane, we can clearly see the vertical superior laryngeal artery and nerves. But today I won’t be so detailed, but I can also simulate how to deal with the superior laryngeal artery if it is accidentally touched.

Expose the thyroid cartilage at the upper edge of the thyroid cartilage, carefully incise the epicartilage, and slowly peel it off to the middle of the cartilage with a tissue stripper to expose the thyroid cartilage plate and form a perichondral flap with the base underneath. Protects outer membrane integrity during separation. "【14】

The speed of entering the pharyngeal cavity was not that fast, and the anatomical structure became increasingly complex. Kawei stopped asking questions, kept his explanations as brief as possible, and focused all his energy on separating the tissues.

"Find the upper notch of the thyroid cartilage and the lower edge of the cartilage, and cut off the thyroid cartilage plate horizontally." Kawei operated carefully and asked Sedillo to protect the thyroid cartilage endothelium, "Do not go down into the laryngeal cavity.

During laryngoscopy, we found that the mass was on Mr. Bizet's right side, so we entered from the left side. The mucosa is incised at the upper corner of the thyroid cartilage, and the pharyngeal cavity is entered. After the position of the epiglottis in the pharyngeal cavity is clearly seen, the pharyngeal mucosa is incised to expand the incision. "【15】

After widening the incision, Carvey used tissue forceps to clamp the tip of the epiglottis and handed it over to Sediyo. Pull the epiglottis forward and outward to observe the location and extent of the tumor.

"Everyone, please see, this is the mass in Mr. Bizet's throat." Carvey moved away and tried his best to clear the field of view for the doctor in the seat behind him. "Compared to 1851, the earliest diagnosis of laryngeal cancer by Dr. Booker in the United States was With dehiscence surgery, my surgical method is gentler and can better ensure the function of the larynx."

At such a historic moment, doctors who had the opportunity in the front row put on masks and stepped forward one after another, hoping to see clearly what throat cancer looks like.

I don’t know when the audience began to applaud gradually, and then the applause was like a sudden rain shower on a summer afternoon. The doctors in the back row couldn't step forward, but a few couldn't help but stand up and kept pumping their hands. Their excitement continued to spread around, and several cameras even lit up their flashes.

Someone in conservative Europe finally chose to be radical, not in a crude way, but in a more sophisticated and artistically beautiful anatomical way, attacking tumors in the larynx, which is also the passage of human life. How can it not be exciting?

".At the time, it was recorded that the patient survived for 15 months after the laryngostomy operation. This is also the longest survival time for patients with laryngeal cancer so far. I hope that after the operation is completed, Mr. Bizet will survive for at least 15 years. "

(End of this chapter)