Nineteenth Century Medical Guide

Chapter 434 430. Another Use of Electricity

All the reports outside are just after-dinner talk. Those outsiders' views and opinions, whether good or bad, no matter how they are worded, have no impact on Kavi himself.

As soon as Shilina's surgery was over, he found Mrs. LaChapelle and John Jr. and performed a careful physical examination and evaluation.

Without testing instruments, the assessment would certainly not be as detailed and precise as it is today, but it would not be as crude as it was in the 19th century, to the extent that people would just measure body weight and call it a day, because there is not even a decent pediatrics textbook now.

Kawi has his own simple assessment method. When the gestational age cannot be accurately estimated, some things can still be confirmed by observation, such as height, head circumference, skin, soles, auricle, chest tissue, etc., as well as basic weight, breathing, and heart rate.

John weighs 2450g, his head circumference is 15% smaller than normal, his height is 11% shorter, his skin is slightly thinner but not translucent, the skin on the soles of his feet is wrinkled, and his ears are well-shaped. His breathing rate is between 35-40, and his heart rate is always above 125 beats/minute, indicating that his body is basically well developed and has no major defects.

This is a typical mature low-birth-weight baby. Surgery is possible, but the preoperative preparation is more troublesome.

The first and most important thing is insulation.

Newborns have a large surface area and little body fat, and produce heat only through shivering and fat metabolism, so they are very afraid of cold. Fortunately, it is June now, and the temperature in Paris is moderate. A simple incubator can keep the temperature around John at around 6 degrees Celsius.

The most troublesome thing is the surgery. The instruments and water used for cleaning are usually of low temperature, and the internal organs are exposed, so it is easy to lose a lot of heat. Therefore, heating and insulation treatment is required in advance before the operation.

The second is calorie intake, which is to prevent hypoglycemia.

Newborns have high metabolism and high fluid and calorie requirements. Adults only need saline or 5% sugar saline for fluid replacement, while infants should use sugar saline containing 10% glucose. For John, who was already underweight, the surgery was urgent and took a long time, so fluid infusion alone might not be enough. He also needed to prepare 50% glucose for intravenous infusion in case of hypoglycemia.

In terms of feeding, some necessary elements need to be supplemented, such as increasing calcium and magnesium. Shilina's body does not have much calcium to give to John, so he can only be supplemented the day before the operation. There is also the problem of low prothrombin in low-weight babies, which needs to be prevented by taking vitamin K.

"Calcium? Magnesium? And soybean oil?" Mrs. La Chapelle was a little confused about what Kavi meant. "How do we supplement these chemical elements?"

"Use calcium carbonate for calcium and magnesium sulfate for magnesium. 1-2g a day is enough. Then add a few drops of soybean oil (each gram of soybean oil contains 2mg of vitamin K) and put it all in the milk." Kavi turned around and asked, "Have you found a mother who is willing to help?"

Although Mrs. La Chapelle didn't understand what eating these two things meant, she still carefully wrote down what Kavi said: "I asked before the operation, and many people are willing to help."

"Ah That's good."

Then Kavi talked about some issues related to blood volume, which contained many things that subverted people's cognition.

For example, a newborn's heart rate is normal at 120 beats per minute or more, and the total blood volume is about 250-300 ml, so losing more than 30 ml of blood is equivalent to losing 500 ml of blood in an adult. They don't have the same respiratory reserve as adults, and if they have airway obstruction like Shilina, respiratory failure will occur much faster, leaving them with little time to think and try.

"The blood type has been tested and the blood preparation will be completed tomorrow morning."

Kavi stood beside John's crib, feeling helpless as he looked at his body which was two sizes smaller than the other children.

According to modern pediatric surgery, there is no need to rush to perform surgery on anal atresia with fistula. Meconium is not solid and can flow out through the urethra. It is enough to clean and wash the baby under cystoscopy. You can wait for half a month of feeding and wait until the baby grows a little before performing surgery.

However, conditions were limited in the 19th century and no one knew the situation inside the urethra. If feces refluxed into the bladder and accumulated and caused inflammation, it would be more trouble than benefit.

It was also his first time to perform surgery on a newborn. Although he knew the surgical method, there were too many uncertainties in pediatric surgery. For example, he had no special means to deal with any anesthesia accidents. He also had hypoproteinemia, acid-base poisoning, and jaundice that was difficult to resolve due to lack of testing.
Just do your best.

Kavi glanced at the assessment record made by Mrs. La Chapelle, and after finding it all right, he asked, "Does the medical ward have a hand-cranked generator, the kind used for electromagnetic therapy?"

"Does Dr. Kavi believe this?" Mrs. La Chapelle was a little surprised. "Yes, it was quite popular a few years ago, but not many people use it now."

"Take me to see it."

[Marshall Company - Electromagnetic Therapeutic Apparatus (1859): A device that used magnets and electrical stimulation to treat a variety of ailments. The wooden box contained a large metal magnet, a wheel and spool, an external hand crank attached to the wheel, and two external handles and cords.]
Soon it was June 6, and almost all surgical departments in Paris hospitals, including the Hôtel-Dieu, rescheduled or canceled all surgeries after 11 p.m. because all surgeons who were going to operate on patients wanted to come to the Hôtel-Dieu to see how Cavi would handle anal atresia.

At 5:30 p.m., the operating theater of the Hôtel-Dieu opened to the public, but only medical practitioners with the surgical association badge and physician's certificate were allowed to enter.

Even with such restrictions, the theater entrance was still crowded with people, and many doctors who were not surgical professionals or whose surgical skills were not recognized by the Paris Surgical Association were blocked from entering.

Everyone was discussing the harm of anal atresia to the baby and how they would perform the surgery if they were in his place. A small group of people did not think that Kawi could complete the surgery, arguing that the newborn was too fragile to withstand the physical damage caused by prolonged incision exposure.

As the doctors took their seats according to their number plates, someone suddenly noticed that the first row of seats in the operating theater was still empty, while the leading figure in the surgical field, who was supposed to be sitting there, was sitting in the second row.

Holmes and his companions, who were specially arranged by Kavi to sit in the fourth row, also felt strange: "Why is there no one in the first row?"

"I heard that it was specially added when Kavey came to Paris for a tour. Later, they found it very good and kept it." James and Wade drew a simple diagram of the operation on the notebook. "If there is no one here, shall we go over there?"

They had done this a lot when they were students, but the situation was different now. New York and Paris were two completely different places. Holmes immediately stopped him: "Don't be silly. How could there be a vacant seat in Dr. Kavi's surgery, and in the first row? I think some important person must be coming."

“But didn’t Paris cancel it a long time ago?”

Just as Delafield was about to mention the association's rule, a loud voice outside the venue called out someone's name: "The great Knight of the Garter, the Earl of Dublin, the Duke of Cornwall, the Duke of Rothesay, and His Royal Highness the Prince of Wales has arrived!"

Bertie was wearing a gorgeous bright red uniform, white breeches and black leather boots, with a golden cape behind him, symbolizing the royal family, and his usual black cane in his hand. On the left was his attendant, Viscount Lytton, and on the right was his female companion, the queen of Parisian fashion, Venetia.

Viscount Lytton was still wearing a dark blue uniform, and Venice was also dressed very formally, even conservatively, and was far less charming than she was at the jewelry exhibition.

As soon as they entered the market, they attracted many people's doubts.

Many doctors don’t understand why a descendant of the British royal family would come with his entourage and his mistress to watch a neonatal surgery that has nothing to do with political women?

Suspicion, innuendo, and whispered abuse filled the theater, but Bertie didn't care.

He took off his cloak, and then urged Viscount Lytton and Venetia behind him to hand over their coats and cloaks, along with their canes, to the intern at the door for safekeeping. Then, according to the surgical procedures written by Kavi, he put on a mask under the guidance of the intern. If Lytton hadn't reminded him, Bertie would have even wanted to take off his uniform and try on the black leather skirt in the surgical preparation area. This action undoubtedly calmed down many objections.

In this era, as long as the royal family can abide by some basic rules with the people, the phenomenon and behavior of the royal family's privileges are justified. The one who should be blamed should not be the Prince of Wales, but the guy who allowed the Prince of Wales to enter the operating theater.

"Her Royal Highness Princess Mathilde Bonaparte has arrived!"

With Bertie in front, the third cousin's entrance seemed much more natural and smooth. With her, her Hungarian handsome man Rochester would definitely be by her side. The two of them entered the venue with smiles on their faces, arm in arm, and followed Bertie's example before, handing over their belongings in exchange for masks to cover their mouths.

"Grand Duke Vladimir has arrived!"

Hearing this address, Bertie was startled and looked up to see that it was the Tsar’s second son he was thinking about: “Why is he here too???”

Although Britain and Russia are divided into the east and west sides of Europe, there are many daughters of the Danish king to serve as a bridge between them.

Grand Duke Vladimir's eldest brother was the eldest son of the Tsar, Alexander, and the brother-in-law of the Princess of Wales. Bertie openly brought a woman of charm to such an occasion. If the news reached London, it would probably be another family disaster.

Litton was sharp-eyed and quickly reminded: "Your Highness, he seems to be..."

"I know. I saw it at the opening ceremony."

"How about I switch places with Your Highness so that you can distance yourself from the matter?"

Bertie: ???
"Don't be nervous, I can handle it."

Bertie reacted quickly and regained his composure in just a few seconds: "Look whose hand he is holding. That's Ortense, the most delicate actress in Paris. I just climbed out of her bed the morning after the opening ceremony. From the day I climbed down to the time he climbed up tonight, at least three royals have climbed up.

Just think about it, if this matter gets to his father's ears, he may not even be able to keep his position as the last deputy commander of the Imperial Guard."

Litton thought: "I see."

After saying that, Bertie quietly stood up, smoothed out the few wrinkles on his clothes, greeted Vladimir in a very high-profile manner, and asked him to sit down next to him.

On the surface, it seemed that there was no relationship between the two, but in fact, the two princes of Britain and Russia understood each other tacitly after meeting. They looked at each other's female companions and couldn't help laughing, and the embarrassing incident passed. As long as Friedrich, the eldest son of the German Emperor and Bertie's brother-in-law, didn't come, they could live in peace.

The remaining three seats are reserved for Hot, the current president of the Surgical Association, the dean of the Medical School of the University of Paris, and Haussmann, who has always been committed to making Paris the center of the world.

Osman's arrival caused some gossip in the venue. After all, many people had a grudge against him because of the demolition of the old city, and since he didn't have a decent title, he naturally became the target of everyone's anger.

Osman was not in Hott's plan. The presence of several royal families had already made the association and the college a lot of money, so there was no need to find a target to cause trouble. But the promise of exempting half of the water diversion project budget really hit the Dean of the Medical College's sore spot, making it difficult for him to refuse.

The operation began in this noisy atmosphere.

Cavi's presence has a muting effect. Anyone who knows him or has seen him perform an operation knows his temper and will not speak casually when he is speaking or working.

"There are indeed a lot of people here today, and I met a lot of old friends."

Kawi exchanged glances with the VIPs in the first row, bowed slightly, and began his opening remarks for today's surgery:

"Everyone should know the content of today's surgery, but before we begin, I would like to introduce the patient's condition. He is the son of a female writer, who was born the night before yesterday. He was born underweight, with a small head circumference and mild malnutrition. In addition, he has serious physical deformities. His anus is congenitally closed and he cannot defecate normally."

After saying that, without any instructions from Cavedo, Peon took the child out, exposed his snow-white buttocks, and walked around the field to show everyone his closed anus.

"Anal atresia used to be a serious deformity that made it difficult for children to survive, often causing them to be unable to defecate and suffer from urinary tract infections. Over time, it would cause rectal dilatation, eventually leading to megacolon and death.

Generally, anal atresia is divided into five types in terms of surgical anatomy: complete rectal atresia, low atresia (Figure A), middle atresia (Figure B), and high atresia (Figures C and D).

Since the meconium was overflowing from the urethra, I was sure that there was a rectal urethral fistula, but I didn't know whether the fistula was in the middle urethral bulb or in the high prostate and bladder. Because I couldn't determine the exact location of the fistula, I decided to try my luck with a posterior incision. "

Kavi asked Payon to place the child chest down on a special operating table: "This is an electrotherapy table that I made with a few friends in Vienna. It was originally used to treat wounds with electric shocks. Later, they found that this idea was difficult to implement, so they changed it to this.

There is a small hand-cranked generator under the operating table, which can output 15-100ma of electricity and play an electrotherapy role. If you are interested, you can go to the Vienna Industrial Exhibition Hall to find Miss Cecilia or Mr. Forrest, product number VI-14-35927.

"Of course, I can't use electrotherapy to open up the rectum and anus for Little John. What I want to show you is another way to use electricity."

"Another use?"

"Any other uses?"

There were many questions and great interest in electricity, an ancient yet new thing. Kavi did not rush to explain, but just asked them to be patient, and then instructed the interns to raise the middle of the operating table, so that John could lie prone on the table and raise his pelvis as high as possible:

"We need to make a posterior sagittal incision from the center of the sacrum to the anal fossa. Before doing so, we need to use muscle contraction caused by electrical stimulation to determine the position of the levator ani muscles in the anal fossa. This is what I call another use, pathfinding. Only in this way can I know where the true exit of the rectum is."

This surgical approach is not common, mainly because it contains too many important anatomical locations, including the urethra, prostate, vas deferens, and seminal vesicles. If the rectum is repeatedly explored, it is very likely to damage important nerves for urination and sexual function, which is not worth the cost. However, for children with recto-urethral fistula, this is the most intuitive location to find the rectum because the invasion is shallow.

Peon and Landreth disinfected the entire buttocks, and Kawi drew a simple surgical incision with a pen: "Anesthetize it, pay attention to the heart rate and breathing."

This is the stage he is most worried about. Whether the newborn can tolerate the side effects of ether depends entirely on fate. If severe arrhythmia or respiratory depression occurs, the operation can only be abandoned. If he can survive, then the first stage will be over.

As the ether vapor slowly entered John's nasal cavity, the nurse reported the vital signs for the first time: "Heart rate 128 beats/minute, breathing 35 times/minute, everything is normal."

"Okay, give me the scalpel."