Nineteenth Century Medical Guide

Chapter 431 427. The controversial second stage of surgery
Imperforate anus does not mean that there is no "eye". The child still has the anal fossa and the eye is still there, but it is only for appearance and has no function. Because of the problem of embryonic development, this place is not connected to the rectum, which is often called congenital anal atresia.

In the 19th century, pregnancy was definitely accompanied by many high-risk factors, and the malformation rate was very high. Anal atresia was a type of rectal anorectal malformation, which was not uncommon. Of course, it was not so easy to detect it immediately. Often, it was not until several days later that the child was found to be unable to defecate and had a severe abdominal distension before seeking medical attention.

It was pure coincidence that Madame La Chapelle discovered it.

When she measured the fetus's measurements and weight as Kawi requested, she found that the meconium was located more toward the front of the fetus. In particular, there was a lot of meconium accumulated around the little penis, while the anus, where defecation should be, was clean.

Then she looked at the size of the child's head and abdomen and found that the child, who should have a big head and a small body, now had a larger abdomen. Only then did she try to touch the anus.

Sure enough, this "eye" was not a door, but a dead end.

"If I'm not mistaken, the white layer on the baby's body should be meconium."

Someone in the audience raised an objection, "But if the anus is imperforate, where does the meconium come from?"

"Yeah, that makes sense."

"Madame La Chapelle has delivered more babies than you've ever eaten oysters. How can she be mistaken about whether the anus is functional or not?"

"I'm just raising an objection, not denying her skills. Why are you so anxious?"

"I"

The two were arguing about a very simple logic problem, but it was something that the American students had not thought of. They kept writing on the paper with both hands and cast questioning glances.

It would be fine if I didn't look at it, but once I did I was shocked: "Why is it him? Why is he in Paris?"

"It must be that his rich father is attending the Paris World Expo, so he just came along to take a look."

"But he's an internist, why is he here to see a surgeon???"

“God knows!!!”

Several people chatted while avoiding sight, huddled together and moved a few steps in the opposite direction, fearing that they would be seen by that guy. Fortunately, the other party's attention was always on Kawi, and Kawi quickly responded to his doubts.

"Stop for a moment, I don't like noisy environments."

Kavi carefully confirmed the child's anal fossa, and then explained: "Mrs. La Chapelle is not mistaken, it is indeed anal atresia. As for the meconium you mentioned, I can only say that anal atresia is not equal to rectal atresia. Many times the rectum is just connected to the wrong pipe and is not completely closed."

The audience, which had been noisy just now, finally quieted down, and many people, like Holmes and others, took out paper and pen to start recording what Kavi said.

"I have dissected many infants and young children, and I have found many cases of anal atresia." Kavi handed the needle in his hand to Landreth, who was responsible for removing the placenta, and observed the child's fingers and toes. "There are several types of atresia. There are completely closed atresia, and there are also atresia with fistulas in other places. This child should have a rectourethral fistula. Meconium will leak out of the urethra little by little along with urine."

Rectal urethral fistula, and the case was of a newborn boy, involves two major specialties: anorectal and urology. From Kavey's reply, it is not difficult to hear that he is quite knowledgeable in this area. This undoubtedly added a "highlight" to the operation, and everyone present wanted to see how Kavey would deal with the rectal urethral fistula.

But for Kavi, the last thing they want to see is accidents, especially children with obvious deformities, who often also have deformities in other aspects.

"Bring me the stethoscope, let me listen to his heartbeat first." Kavi placed his hand stained with blood and amniotic fluid on the edge of the incision, then turned his head and asked the nurse to put the stethoscope on him. "Put the stethoscope head a little higher on the chest, closer to the middle. Then go to the original place a little outside, downward, to the apex of the heart."

The person who had just questioned La Chapelle could not help but speak up again: "Excuse me, Dr. Kavi, why do you want to listen to a baby's heartbeat? Isn't his problem anal atresia?"

"Why did he start again!" Holmes couldn't help but complain.

"It's not the first day you've met him."

"Dr. Kavi is listening to the heartbeat now. Heartbeat, that's his field. How can I not say a few words to justify the paper I wrote back then?"

"That's true."

The two consecutive questions aroused the disgust of many people. The French doctor who had just refuted him began to be eager to try again. Looking at the whole audience, perhaps only Kavi found it very interesting. Before anyone else could speak up, he asked back: "I wonder if you have heard of heart murmurs."

"I've heard of it." The man on the stage replied.

"Five years ago, an American physician wrote a paper that emphasized that a type of heart murmur that only occurs in heart disease can be clearly heard using a binaural stethoscope." Cavey briefly introduced the doctor. "The doctor's name is Austin Flint."

“I didn’t expect Dr. Kawi to focus on internal medicine.”

At this time, Mrs. La Chapelle beside him whispered to Kavi, and Kavi realized that the other person was Austin Flint: "It turned out to be the author of the treatise himself. I didn't expect that Dr. Flint, who specializes in cardiology, would also pay attention to surgery."

Flint didn't get angry after hearing what Kavey said, but simply replied: "Internal medicine and surgery are both medicine, serving patients, there is no essential difference."

"That's right."

Flint immediately got back to the point. "So, why would you listen to the heartbeat of a child without an anus?"

Kavi asked LaChapelle to take the baby away, and then began to examine the placenta that Landreth had detached: "Humans develop slowly from an embryo. No matter what goes wrong with the body at birth, it is a developmental problem. Since there is a problem with the anus, there may be a problem with the heart. Unlike other problems, if there is a problem with the heart, there is no way to go on the operating table."

This explanation based on the theory of uterine development left Flint no room for error, but Kavi's further explanation was a bit beyond the understanding of the father of heart murmur.

"The child's heart still has a little murmur, and the location is very subtle. It may just be physiological, but I can't make a judgment now. However, there is no sign of hypoxia on the skin, and the breathing rate is okay. Even if there is a problem, it is not fatal."

Where is the noise?
Physiological? Pathological?
Murmurs and hypoxia? Respiratory rate? This passage is not just a simple description of the child's physical condition, but a piece of experience that would put even the most authoritative "Internal Medicine" to shame. Surgery focuses on technology and doesn't feel anything about this, while internal medicine focuses more on experience. For the first time, Flint felt the insurmountable experience gap in a person, like a mountain.

Although it was only a brief moment, it was enough to shock him.

He wrote down this sentence word for word in a notebook and thought about it over and over again, so much so that in the end he lost interest in watching the operation and left the operating theater directly.

In the 19th century, it was difficult to treat newborn deformities, and as long as they did not affect life, they would not be treated. Even the simplest deformity, such as an extra finger, would be prohibitive due to the complications after surgery.

For complicated congenital malformations like anal atresia, surgery will not be challenged to its limits. The normal survival of children with congenital malformations is to live as long as possible. Of course, there are some attempts, but most of them are complete atresia without leakage and fistula. Surgery is just to save lives and to create some precedents for the ignorant pediatric surgery.

This type of surgery has been in the development stage since the last century. People often take risks, but there are not many successful cases.

Kawi has indeed seen relevant reports, which simply make a stoma on the lower back or abdominal wall, but the suturing method is flawed, leading to complications such as stoma collapse and retraction. Even if it succeeds and ensures the child's basic defecation problem, it will also strangle his life.

"I remember that 30 years ago, at the Hospital Main, Dr. Amusat performed lateral lumbar stomas on 29 patients, including those with colon and rectal tumors and infants with anal atresia. The survival rate was less than 30% in the end."

Kawi returned to the surgery in front of him and continued, "If we don't take into account adult cancer patients, only 21 of the 4 children born with anal atresia were saved, which is less than 25%. Considering the series of problems caused by artificial anus stoma in subsequent life, the chance of living a full 10 years will definitely be reduced."

There was no anesthesia at the time, so the survival rate was already very good.

"I am not doubting Dr. Amusat's skills. After all, he is one of the most outstanding students of Dr. Dupont Itran, the former surgical emperor of this hospital. There was no anesthesia at that time, and the operation was always accompanied by twisting limbs and heart-wrenching screams. The stoma itself does have quite a lot of complications, including retraction, stenosis, inflammation and malnutrition."

Kavi glanced at the shrinking uterus, briefly asked about Shilina's vital signs, and continued, "But it is undeniable that a simple colostomy is not suitable for this child."

This statement once again caused quite a stir in the audience.

Ostomy, which is a procedure to transform the original passage and restore the defecation function, has always been considered a very delicate surgical procedure in everyone's eyes. It is difficult for them to imagine how dangerous a more complicated operation would be, so they do not believe Cavi's conclusion rationally.

It's just that this young man has already made many surgical records, so while they denied it verbally, they still had expectations in their hearts.

“Without a stoma, how will the feces be discharged?”

"I heard that Dr. Kavi has made great achievements in the field of urology. Does he want to use the rectourethral fistula to transform the urethra to complete the two-in-one feat?"

"It's a very imaginative thought, but unfortunately it's not feasible."

"How do you know it's not feasible? Have you tried it???"

"Do you even need to try? If you've studied anatomy, even in the worst medical school, you should know the difference between the urethra and the rectum!"

"Everything is possible. How can you know how to innovate if you don't try? Are you going to stick to the same old surgical books forever? The conservatives should get out of Paris. I don't want to see a surgical center like this fall into the hands of people like you!"

"You are the criminal in surgery! Any innovation that is not based on basic theory is nonsense! It is a stain on the increasingly sophisticated surgery!"

Perhaps stimulated by Flint, after he left, some people in the audience still questioned the surgical plan, and even chose to use vicious language to criticize the other party. This phenomenon is very common in academia and elsewhere, but Kavi doesn't like it.

"Quiet! I said, I like quiet!!!"

Kavi used the replaced vascular clamp to knock on the metal stent beside him. After everyone responded, he threw it into the washing basin. "If you want to argue, go outside the theater. If you want to have a duel, that's totally fine. I think the patients of the Hospital Dieu are very happy to see the doctor fight to the death in front of them because of a trivial quarrel."

"."

Kavi sighed and sewed the last few stitches on Shilina's uterus with a needle. "After this operation is completed, I will do a full-body evaluation of the child to see if it is feasible to do anal surgery directly. If you are still interested, please pay more attention to the operation time of the Main Palace Hospital in the next few days."

When the uterus was sutured, the focus of the audience seemed to return to Shilina.

Kavi checked the area around the uterus and found no damage or bleeding. "Shelina is doing well. Her heart rate and breathing are faster than before, but her uterus is contracting well and the bleeding is minimal. At least the cesarean section went smoothly. More than half an hour has passed, and we still need at least another hour to resolve the roundworm intestinal obstruction."

The shrunken uterus released a lot of abdominal space, and the intestines that were originally squeezed around fell back to their original position. Without Cavedo's searching, a dark and swollen intestine appeared before his eyes.

Landreth was quick-witted and quick-handed. He quickly used a baffle and hemostat to create vision for Kavi and pulled the intestine out of his body.

Under the soft kerosene light, the intestine seemed to be only lacking blood, not completely necrotic. On the upper jejunal mesentery side, many large bulging diverticula could be seen: "Because of the abnormal pressure caused by the long-term presence of ascaris, many diverticula appeared in the intestine. Although it has an impact on the intestine, there is no bleeding or perforation, so we will not touch them for the time being."

The surgery procedure was not changed due to any unexpected events, which is a good sign.

Kawi gently rubbed the intestinal wall with his fingers and found the area where the roundworms were located, and found a lower position. Landreth lifted the intestinal wall on both sides, and Kawi cut it open with a blade. He saw the white wriggling worms seemed to have found a new direction and drilled out of the intestine.

But what awaited them was Kavi's ruthless oval clamp and iron barrel.

The roundworms were squirming and curling in the bucket like cooked spaghetti, and the operation was already sprinting towards the final victory. Many people in the audience stood up to cheer and applaud, including Holmes and his other two classmates who were extremely excited.

However, Kavi is well aware of the dangers of surgery, and he always thinks about the loopholes in the operation when others are celebrating success. Even if there are no loopholes in the whole process, he will at least ask the nurse one more question: "vital signs."

"Heart rate 108, blood pressure 2/97 measured 53 minutes ago."

"My heart rate is a little faster than before, but it's still under control. By the way, how's your breathing? How's your breathing?"

The nurse placed her finger in front of Shilina's nose, frowned slightly, and after a few seconds she answered hesitantly, "Her breathing... her breathing seems a little weak."