Nineteenth Century Medical Guide

Chapter 446 442. Letter from the Dead
Looking back at the history of surgery, orthopedic treatment methods are the most revolutionary.

From common external wrapping before the Common Birth of Christ, to traction therapy more than 100 years ago, to plaster fixation repair in the early 19th century, and then to the end of the 19th century, foreign objects began to be gradually used to achieve bone suturing, bone riveting, bone reduction and fixation.

Through repeated attempts and uses, the materials of these foreign objects have also developed to varying degrees.

The first choice was wooden rivets, which were soon abandoned. Later, bones and ivory of other animals were chosen for connection, but they were also abandoned because they were not strong enough. Until the beginning of World War I, metal became the recognized best choice, and internal fixation with screws, bone plates and intramedullary nails also became an important means of treating fractures.

[Intramedullary nail locking mode diagram, the intramedullary nail is driven into the bone marrow cavity and locked with screws above and below]
After metals were identified, materials also developed further, and silver, aluminum, iron, copper, and steel successively became important materials for making intramedullary nails and fixation screws. However, due to the poor compatibility of metal materials at that time, they were prone to electrolysis and corrosion, resulting in loosening of fixation and difficulty in achieving the fixation effect.

Until stainless steel entered the field of vision of orthopedic surgeons, and then it was the world of titanium alloy.
Kavey definitely didn't have stainless steel, and he didn't know much about how stainless steel came from. All he could use was ordinary steel provided by Laszlo's steel company. No matter what material it was, it was better than those ordinary metals, so he used it first.

Putting aside the shortcomings of the material, Kawi still has considerable advantages.

The internal fixation that was developed earlier has certain advantages in dealing with closed fractures, but its disadvantages are magnified in the face of open fractures.

Intramedullary nails can cause inflammation, making the already contaminated wound surface even worse. Plates and screws can accelerate bone healing, but internal fixation requires suturing under the skin, and the materials used are not up to standard. After considering many factors, Kawi chose external fixation.

Of course, in the eyes of others, both the concepts of internal and external fixation are very advanced, and the visual impact is probably greater than that of cesarean section.

"Mid-tibia." Kavi stopped and looked at the two young men who had just finished reducing the bone. "I have just told you the key points when inserting the needle. The main thing is to avoid blood vessels and nerves. Now the question is, what should be avoided in the mid-tibia? What should be the angle of needle insertion?"

Holmes and Albaran looked at Devin's right calf, not knowing how to answer for a moment.

Holmes was a physician who had studied anatomy but had spent so much time on it that he had forgotten its structure. Albaran, on the other hand, had devoted his attention to abdominal surgery and his knowledge of limbs was limited to amputation.

Amputation does not require special knowledge of complex anatomical structures. You just need to deal with the area where the separation occurs. If a blood vessel is broken, the worst that can happen is a little bleeding. You can just use a more aggressive suture to tie it up. Finally, leave a muscle flap for wrapping, and the amputation is complete.

Kavey's surgery belongs to modern surgery. It looks like it uses exaggerated metal instruments, but the operation is more delicate and requires more comprehensive anatomical knowledge. Because a mistake can cause a chain reaction and cause serious sequelae.

"do not know?"

Kavi was a little disappointed and turned his head to look at Landreth. He was not asking him about the anatomy, because he knew that Landreth must know the distribution of blood vessels and nerves in the lower leg, otherwise he would not have been able to sit in the position of Chief of Surgery.

He was just expressing his regret with his eyes that the surgery department of the Grand Palace Hospital currently lacked young talents.

"Why are you looking at me?" Landreth said as he touched the reset tibia. "Young people need experience. They have never undergone this kind of surgery, so naturally they don't understand the anatomical relationship."

"I see you understand it quite well."

"I've been through war, it's different."

Landreth learned very quickly and immediately realized that he couldn't puncture the tibia at the angle that Kavey had just used: "You are not doing it right. The angle is wrong. If you drill in from the same angle, once you pass through the posterior cortex of the tibia, it will affect the blood vessels and nerves. The shaft is the thinnest part of the long bone, so it's easy to..."

[Only the medial and anterolateral directions of the mid-tibia can avoid blood vessels and nerves. Needle insertion in the direction of the red dotted line will have the risk of damaging the deep peroneal nerve and anterior tibial vessels]
"I know." Kavi passed over the fracture. "I didn't say to put the needle in here."

"Then what are you asking?"

"just asking."

Kavi usually didn't ask questions, but this time he discovered what Holmes was thinking, so he tried to ask. Unfortunately, it's not easy to switch from internal medicine to surgery, and he still needs experience. As for Albaran, as Landreth said, he is just a novice who has been working for less than two years. There is still a difference between memorizing anatomical terms and mastering and applying them proficiently, which is understandable.

The third and fourth needle entry points were set by Kawi at the distal tibia.

"This is a good spot." Landreth looked at the plane position chosen by Kawi and said, "We will encounter blood vessels and nerves both in front and inside. The front and inside side is just the right place to insert the needle."

Kawi marked the position and had two pads brought in. One was used to point under the right half of Devonke's buttocks to raise the overall height of his right leg. The other was placed under Devonke's right ankle to expose more space.

Kawi didn't say anything. Landrez and Albaran, who had probably seen it before, didn't say anything and just did as he was told. But Holmes showed a strong desire to learn: "Doctor Kawi, is this to avoid touching his left leg during the operation?"

"Well, I guess so." Kavi looked up at him and asked, "What else?"

"besides."

Why did you ask a counter-question right after answering?
Holmes was confused. He felt that Kavey was very mature the last time he watched his surgery. The so-called maturity is not the ability to deal with people and things that is trained in a short period of time, but the attitude that is accumulated over a long period of time in identity and technical confidence.

In just a few seconds, between the question and the answer, Kavey completed the transition. His movements and tone were very smooth, as if the assistant's question and the subsequent counter-question were all prepared by him long ago.

Holmes knew this was impossible. The impromptu questions asked by the operating table and bedside were a result of the huge workload of the senior doctors. It was a conditioned reflex. He had had the opportunity to experience this several times in New York, but none of them could compare to today.

Kawi is like an old doctor who has worked at the operating table for decades and has taught countless students. He is in control of all situations.
"Huh? Are you distracted? Why aren't you talking?" Kavi tapped the back of Holmes' hand with a steel needle, "Speak!!!"

"Oh! I'm sorry!" Holmes apologized quickly. "Dr. Kavi did this so that he could treat the affected limb from all angles. If necessary, he could also insert the needle from other angles. It's just..."

"Just what?"

"I'm not sure how to use the steel needle, so I'm just guessing." Kavi didn't look at him this time. Instead, he used a scalpel to cut the skin in front of the tibial tubercle, and then used a retractor to pull the skin open: "Come on, help with the retractor!"

Every surgical operation can affect the outcome of the operation. Simply cutting the skin and separating the subcutaneous tissue is an important part of the external fixation process: "After cutting the skin, we need to separate it until the surface of the tibia gives me a periosteal elevator.
There is a layer of periosteum on the surface of the bone, and it is necessary to use a periosteal elevator to lift the periosteum and clear the surrounding soft tissue as much as possible to prevent the soft tissue from winding and necrosis when the steel needle drills in. Necrosis means infection, which is the biggest enemy of surgery. "

Holmes benefited a lot from the hook retraction alone, and the subsequent drilling and needle insertion were even more eye-opening. He felt that if he had not come to Paris, he would probably never have seen such an operation in his life.

Of course, the most excited person during the entire operation was the Prince of Wales who was sitting in the audience.

Ever since Kavi took out two boxes of strange-shaped steel instruments, he had been impatient and kept discussing treatment methods with Viscount Lytton: "You have also been a first aid worker. How do we treat open fractures in London?"

"Amputation, of course."

Litton stared at the operating table and said, "You should remember Baron Kells who went hunting with us last time. He accidentally fell off his horse and fell down the hillside. His foot was broken like this guy's, with the bone exposed. That night, it was cut off by a doctor who had just graduated a few months ago."

"Oh, yes, that's true." Bod thought of that guy. "I can brag about it later because I was on the battlefield."

"But the problem is that we haven't fought a war in a long time."

"That can also be a hero saving a beautiful girl."

When Bertie watched Carvey twist a steel needle into a bone with a T-shaped handle, he would tense his muscles as if he were doing it himself: "This operation doesn't look difficult. I feel like I can do it, too."

If Lytton hadn't quickly grabbed his shirt, Bertie would have stood up and asked Kavi to let him go to help: "Your Highness, don't do this. This is an operating theater, not Queen Victoria's bird garden."

"Ah? What are you talking about? I just want to go down and take a closer look."

Litton knew him too well to believe it. "This is a miraculous moment of witnessing wound healing. Just like what you said when you rejected Miss Venice, 'It is rude to disturb them during the operation, and it will cause problems for Dr. Kavi.' Your Highness is so smart, he must remember it."

"Oh, well, I'll just stay here."

Bod understood what he meant, just like a child whose toys were suddenly taken away. After crying and making a fuss, he realized that it was useless and had no time to feel sad. He quickly thought of something else: "Speaking of Venice. It would be nice if she was here."

"Huh?" Litton was startled, thinking that Bertie was going to look for that wanton woman again, and quickly reminded him, "Didn't you just make a clear line with her a few days ago? And as far as I know, she just met with Nathan last night."

"What are you thinking? Wait, that old guy still has energy? Never mind, it doesn't matter." Bertie quickly denied his guess, "I just want her camera. She loves taking pictures so much."

While the two were chatting, Kavi had already inserted two steel needles, and the external fixation operation slowly entered the final stage.

Kavey placed metal joint sleeves on the two steel nails at the proximal and distal ends of the tibia, inserted the support sleeve rods into them, and tightened the nuts to simply fix them: "Let's release the fixing clamps first."

"Let go now?"

"Well, let it go. Holding it for too long is not good for the bones, and it has already shifted a little."

After all, the clamp is just a clamp, not a real traction tool, and the clamping surface is bound to slip. Kawi used his hands to block the rod and the wound, watching Albaran and Holmes remove the clamp, and Devinke's tibia shifted slightly again.

However, because the rod was fixed, the degree of displacement was far less exaggerated than before the operation and was still within an acceptable range.

According to the marks he had made previously, Kawi inserted two more steel needles into the tibial shaft, and then during the second traction, he loosened the nut and used the rod-sleeve joint as a guide to gradually pull and fix the joint, achieving a rough reduction.

Limited by the quality of the equipment, the only external fixator that Kavey can use now is a four-pin unilateral fixation bracket. Compared with the modern silky sleeve mobility, the one he has is very difficult to use, and often gets stuck and is not fixed firmly.

But for an open fracture that existed in the mid-to-late 19th century, this was a complete technological revolution.

While everyone in the operating theater was still sighing that such a troublesome and serious injury was properly resolved within two hours, Kavey had already begun to assess the general's wife's injuries: "The general's wife's injuries are lighter than Mr. Devinke's. There is no exposed fracture end, and the amount of bleeding is not large. I think we can give up external fixation and choose another set of fixation materials, steel plates and steel nails."

At this time, on the way to the Tuileries Palace, the hooves of a carriage were clattering, and the coachman's whip was constantly swinging with the ups and downs of the carriage.

Ten minutes later the Tuileries Palace appeared before him.

The last rays of sunset shone brightly on the golden gates, and the guards stopped the carriage. After checking the ID of a man in black and the military medal of the Austrian Empire, they all moved aside.

The carriage continued forward, crossed the wide square, and entered a side palace gate under the watchful eyes of hundreds of soldiers. This was the temporary residence of the Austrian emperor and his queen, who were also the rulers of the newly merged Austro-Hungarian Empire.

After getting off the carriage, the man in black came to the reception room under the guidance of the adjutant Kleville who was anxiously waiting at the door, and personally handed an important document and a letter to Franz.

Franz and Elizabeth, who had just experienced the explosion, were still in shock. The impact of the explosion was deeply engraved in their minds and it would be difficult to dissipate in a short time. Fortunately, Casper brought good news. After learning the fate of the two murderers, the two of them calmed down a little and immediately withdrew their suspicion of Morasso.

However, when Franz unfolded the letter that came with the confession, he immediately recognized the handwriting on it. It was the handwriting of Mik, the former director of the Paradise Library and the head of the secret police organization.

This is a letter from a deceased person.