Nineteenth Century Medical Guide

Chapter 390 386. Weighing the pros and cons of choice

Kawei's sudden appearance made the lifeless atmosphere suddenly become heated. People were talking a lot. Some excited people would stand up and wave to him, and the more enthusiastic ones would shout a few times. Some even set up their cameras early. Reporters began to snap pictures frantically.

Kawei did not criticize the two chief directors. Instead, he sincerely appreciated their decision. This is why he deliberately waited until the operation was close to closing before showing up.

There were too many uncertainties in surgery in the 19th century, anesthesia was unstable, vital sign monitoring was too rudimentary, and emergency drugs were almost non-existent. Every operation is like throwing dice on fate. The difference is that other people's dice have fewer sides and more bad luck. Kawei's dice has more sides and very few bad luck.

Classic metastatic right lower quadrant pain and very obvious McBurney's point tenderness are clearly stated in Carvey's diagnostic instructions as typical symptoms of the appendix.

Everyone feels different. Appendicitis may have atypical symptoms, which is normal. Therefore, diagnostic errors are common. But when the symptoms are so typical, could the diagnosis still be wrong?

This is the main problem faced by the two directors now.

Of course they knew that it was probably not appendicitis, but that there was probably something else going on. Their surgical skills are at the top of the modern era, and their treatment methods are more powerful than most doctors, but they are still worried about the side effects of long-term operations.

However, laparotomy, as a common surgical method in modern medical emergency, was quite dangerous at the time. Even though intraoperative rehydration is now available, they have sufficient knowledge of abdominal anatomy, and simple alternatives to antibiotics, they are still unsure and afraid of problems.

Unlike the previous laparotomy without a clear diagnosis, this surgery gave a clear diagnosis.

In a completely public place, an operation with a clear diagnosis is performed. If there is a problem during the operation, the incision is expanded to find the cause. It will be fine if the cause is found in the end. If it is not found, it will be a great loss of face for both yourself and the hospital. It would be even more troublesome if the patient failed to control the surgical process after expanding the incision and the patient died on the operating table.

"Are you sure that the tenderness at McFarland's point is very obvious?"

"Yes, the pain started in the abdomen the night before yesterday. When I came to the hospital at noon yesterday, the pain gradually moved to the right lower abdomen." Ignatz explained, "I checked and found that there was tenderness in the right lower quadrant, especially Max's tenderness, which was the most severe."

Maybe the abdominal pain is only temporary, and the cause of the abdominal pain may disappear on its own. Maybe the abdominal pain will disappear after the operation. Maybe you can seek help from an internal medicine department. Maybe the abdominal pain is really caused by the appendix.

The more they have this escape fantasy, the less they dare to look for another possible "non-existent" cause. Therefore, after weighing the pros and cons, the two people who often choked each other decided to surprisingly unanimously decide to quickly cut out the "diagnosed" appendix and choose to close the abdomen.

"Of course!"

"I asked, but no."

"Have you asked about the history of trauma?"

"nor."

"What about overeating? Like a night out in a pub or a roadside restaurant with friends."

Being able to ask this question is better than 99% of doctors, and Kawei is quite satisfied.

He deliberately waited until the appendix was removed before showing up. Firstly, it confirmed their approach of removing the appendix and gave him a step down. Secondly, it was also because he had the confidence to discover the cause of the disease.

It is obviously much more difficult to truly convey this understanding to the outside world than to directly complete the operation. You never know how many people without any medical knowledge will stand on the moral high ground and carry out unscrupulous moral output. Instead of making things worse, it is better to end it hastily and make a summary after the operation, taking each step step by step.

Probe under existing incision? Just an incision less than 10cm?

Ignatz inevitably glanced at Sediyo at Isuke's position, and the only answer he got was shaking his head. When he wanted Jack, who had been transferred from second assistant to third assistant, to step down and give up his position as chief surgeon, Kawei suddenly said: "No, I didn't say I wanted to go on stage."

Of course Kawei knew what they were thinking, and he also knew that they were not doing this all for themselves.

Kawei walked down the steps, handed his clothes to the nurse who came forward, changed into a clean leather skirt and a mask, and then walked to the sink: "Have you carefully explored the abdominal cavity? I mean under the existing incision Exploring.”

"Tell me about the patient's condition." Kawei, wearing a new black coat, slowly walked down the steps, "Is there metastatic right lower abdominal pain?"

"Ah? Why are you washing your hands if you don't go on stage?"

"Where's the diarrhea?"

Kawei nodded, waved to the nurse in the distance, took off his coat at the same time, and asked as he walked: "Are you vomiting?"

"I asked too, but no."

This is determined by medical education and the background of the times. If you want surgical data, if you want to maintain your reputation, and if you want patients to survive longer, you have to give up your desire for knowledge.

"No."

"I'll take a look."

Kawei pointed at the patient on the operating table. Don't look at me, look at the patient, look at the incision, look at the intestines inside, and the omentum that maintains the intestines: "Look at whether there is bleeding when flushing the abdominal cavity? Look at the omentum." Edema?"

Flushing before closing the abdomen is a routine operation, mainly to remove blood clots left in the abdominal cavity and to eliminate bleeding points hidden in dark places. There is no prescribed amount of Kawei's flushing. The only standard is that the flushing fluid aspirated cannot be bloody. That is, as long as redness is visible to the naked eye, even if it is a very light red, it must be done again.

This was quite a luxury in the 19th century when clean water resources were extremely scarce. Every basin of clean water had to be sedimented, filtered, boiled, and cooled, all of which were labor-intensive. Naturally, they could save what they could.

"Look at the suction bottle." Kavi pointed to the bottle behind them with his toes, "Is there any blood?"

Cediyo nodded and said, "Yes."

Ignatz also wanted to defend himself: "It's a very light red."

"Expand the incision." Kawei rubbed his soapy hands back and forth with a small brush, "Hurry up, don't look at me, I told you I won't go on stage."

Ignatz took the scalpel that Karen had already handed over, and continued to extend the incision to the upper abdomen along the upper end of the McBurney's point incision: "Since the swelling of the appendix is ​​not obvious, and the flushing fluid is red, it is considered that there is active bleeding, and it is suspected that there are other If there is a possibility of disease, the incision should be extended now.”

While they were extending the incision, Kawei explained to the audience while washing his hands: "The patient's appendicitis is definitely, but it is not acute, but chronic. This chronic inflammation + the symptoms of classic appendicitis have successfully misled us. In fact, The patient’s condition was completely different from the preoperative diagnosis.”

As soon as the words were spoken, the moment the incision was opened, the four people on the stage took a breath.

The fluid remaining in the abdominal cavity has been stained red, and omental adhesions were found slightly away from the ileocecal part, as well as obvious congestion and edema.

"What's happening here?"

"Omental torsion may be accompanied by omental dysplasia." Kawei washed off the soap suds on his hands and explained, "It is a relatively rare condition, but because the symptoms are very similar to appendicitis, I remember it very clearly. That was long ago in Lombardy."

The explanation is naturally the same as before.

He and his father dissected a patient whose surgery was successful but whose postoperative abdominal pain worsened and led to death. Finally, it was found that the patient had peritonitis caused by torsion, obstruction, and necrosis of the greater omentum. The inflamed appendix diagnosed preoperatively showed no obvious abnormalities. "This situation is rare, but if it does occur, you need to highly suspect that there is a problem with the greater omentum." Kawei explained, took his hand out of the water, wiped it dry, put on gloves, and then inserted it into his leather skirt. In the small front pocket, "Teacher Ignatz, what should I do next?"

"The torsion has caused serious blood vessel blockage, and the swollen omentum cannot be removed," Ignatz said. "Just cut off the omentum."

It is much easier to deal with the necrotic omentum than to deal with the intestinal tube. It is enough to carefully separate the adhesions caused by inflammation, then block the blood vessels and cut off the necrotic tissue.

After more than half an hour, the operation ended.

Kawei watched from the sidelines for more than half an hour without any intention of taking action. This has successfully attracted the attention of many people, and is at least much more interesting than omentectomy surgery.

"I wash my hands for the next patient." Kawei explained after the operation.

The next patient?

That inguinal hernia? Isn't the diagnosis very clear? Is there a problem with that?

Ignatz glanced at Cediyo again, his mind running wildly through various conditions of the patient, and then he wanted to see some hints from the eyes of the chief director of the Palace Hospital. It's a pity that Cediyo didn't know more than him, so he just shook his head slightly.

"I have been to the preparation ward before and did an examination." Kawei asked Jack to do the final suturing work and called the two directors off the stage, "Let's talk."

Ignatz changed from his normal behavior and immediately reported the medical history: "Elderly male, 63 years old, with main complaint of abdominal pain for 3 days and no flatus and defecation. I asked about the medical history, but he was a Czech and he had a strong dialect accent. , even the family members could only get a rough idea. After asking around, they found out that he had abdominal pain and inguinal hernia for more than 7 years. "

"The physical examination revealed that the abdomen was bulging and there was a huge mass in the left vaginal sac." Cediyo continued, "The diameter was measured to be more than 10cm. The texture was very hard to touch and there was obvious tenderness, which could not be recovered."

"Do you have body temperature?"

"No."

"What about other tests?"

"There was tenderness in the left abdomen, insignificant rebound pain, and slight tension in the abdominal muscles." Ignatz explained. "The clear diagnosis at that time was an incarcerated hernia in the left groin, which may have peritonitis caused by intestinal necrosis."

Kawei nodded, everything from physical examination to diagnosis was fine. The two directors already had modern physical examination and diagnostic capabilities. But the shortcomings are still there, just not so obvious.

"Have you done your ward rounds this morning?"

"Checked," Ignatz replied, "It's still the same."

Kawei's questions began to become tricky, and they didn't even have much to do with surgery in the 19th century: "Have you ever been reminded not to eat?"

"I'm specifically reminded that you are not allowed to eat before surgery."

"Where's the water?"

"Of course we said it together."

"But he still drank a lot of water." Kawei warned with a "You don't know" expression, "Just persuasion and instructions are useless. Someone has to remind him from time to time and keep looking at him. and his family."

Both directors understood the truth. The problem was that drinking water affected the anesthesia and the surgery itself, not the diagnosis. It is impossible for a patient with an inguinal hernia to have her hernia disappear just because she drinks a few bottles of water.

"What does this have to do with diagnosis?" Ignatz didn't understand.

"Of course it does matter." Kawei looked back at Jack's sutures, gave a few words of guidance, and then said, "Because the abdominal pain has become more obvious."

Cediyo didn't understand either: "When food, including water, enters the digestive tract, intestinal peristalsis will naturally occur, which will also lead to incarcerated hernia. Pain is normal."

"But the location has changed."

Kawei said the key: "The location of the pain has changed from tenderness in the left lower abdomen to tenderness in the left side of the abdomen, with a tendency to spread further. Of course, there is rebound pain, and the abdominal muscles are also very tense."

Modern hospitals will not keep patients with emergency abdominal pain overnight. They will send them during the day and the operation can be completed that night at the latest. Such efficiency is unrealistic in today's Vienna. Being able to perform surgery today is already very good. The mistake was that there was no dynamic and repeated observation of the condition, and changes in symptoms were missed.

The first one had just finished the operation, and after a short cleaning, the second one was sent to the operating table.

This time it was Kavi who explained the patient's medical history: "Mr. Thomas Katona Novak, a Czech, was once a well-known blacksmith. Years of hard work caused him to suffer from an inguinal hernia that was difficult to heal on its own. , eventually causing intestinal incarceration.

But just like the chronic appendicitis operation just now, it was omental torsion that ultimately caused abdominal pain. The cause of this old blacksmith's disease is also confusing. Why did the hernia, which had been tolerated for seven years, cause severe pain, and why did the pain begin to spread throughout the abdomen? There is no absolute medical diagnosis, and the next surgery will reveal it. "

Returning to Vienna again, Kawei became more and more skilled in facing big scenes, and even learned how to whet the audience's appetite, which attracted a lot of applause.

Because of his early appearance and word of mouth, this inguinal hernia station, which had less than half of its occupancy rate, started to receive many people one after another, and is now almost full.

Ignatz watched the flow of people continue to pour in, changed himself into a pair of clean gloves, and helped clean the newly used instruments, and said to Kawei: "Finally, you are alive. If you can survive for a while, You will bankrupt the surgical theater."

"I didn't rest either."

Seeing that Kawei talked about the conversation with Laszlo in an understatement, Ignatz didn't want to ask more questions, so he changed the subject: "I heard that you saved a young man in Zurich?"

"Rescued a young man?" Kawei hesitated for a moment, realizing that he was asking Geizer, "Oh, that frivolous boy who is obsessed with painting."

kid?

You still call others brats?

What Ignatz cares about is the surgery: "I heard from Sediyo, it's a very beautiful skin grafting. You didn't do much of this in Vienna. Now that you're back, you have to teach me! There's an anatomy room in the There are two male corpses, which is quite new, otherwise"

"Let's give it another day. I still have a dinner party tonight." Kawei counted the time, "How about next week? Alphonse should be here in the next two days, and the surgery he will do after he arrives will be much better than skin grafting."

(End of this chapter)