Nineteenth Century Medical Guide

Chapter 448 444. Is this a technique that can be obtained through hard work? ? ?
Just outside the walls of the Tuileries Palace, the entire royal palace area was not affected by the explosion at the train station in the afternoon and still maintained its hedonistic nature.

This place is to Paris as Paris is to Europe. If the goal of life is to entertain oneself to death, then this is their only choice.

Under Haussmann's careful planning, the Tuileries Garden and the Royal Palace are the center, surrounded by grand hotels, salons, and art galleries. Outside are all kinds of porcelain shops, jewelry stores, bars, casinos, and places where all kinds of women clearly mark their prices. Almost every street and alley is filled with all kinds of temptations.

Like most international students who come to France, although Delafield and Janeway are studious, hardworking and smart, their life in Paris is generally indulgent.

They would not mention these in their private diaries or letters home, and they still remembered the warnings from their parents and teachers and the dangers of syphilis, but they felt an independence they had never experienced before. This complete freedom, without supervision or interference, and everyone living their own lives made them feel truly alive.

However, after living in the United States for twenty years and receiving twenty years of American conservative education, their bottom line is not to gamble or be a gambler.

In addition to studying in medical school, they occasionally worked in the hospital. The rest of their time was spent on the pool table and playing cards, accompanied by champagne and wine that was much stronger than in New York, and the "Cinderella" found by the theater, which together made up their study abroad life in Paris.

These girls usually earn a meager salary, and only a few francs are needed to make them fall in love with you faithfully. They are a buffer zone for many international students when they are struggling to reach the bottom line.

June 6 was nothing special for them, because they had no plans to go to the hospital. After completing their medical school courses, they worked hard in the anatomy room and library for more than three hours. At about 19 o'clock in the evening, they were going to call Holmes to find their respective women to drink and play cards, and spend the evening.

But Holmes was not in the apartment and was nowhere to be seen.

After a night of lovemaking, they got up at nine the next day, had breakfast, read the breaking news in the newspaper, and then went their separate ways. The girl went to rehearse the opera, while the other two went to medical school to continue their studies and work.

However, when they arrived at the school, they still didn't see Holmes.

It was not until the afternoon that they realized the seriousness of the problem. This friend had been missing from their sight for a full 30 hours. When Holmes was found at the Hôtel-Dieu, it was already pm.

He was sitting at the desk in the surgical ward, still wearing the same clothes he wore when he came to see Landreth the day before, and he smelled strange. When Holmes saw them, he just glanced at them briefly and then buried his head in his notes again: "Hey~ Why are you here? Don't you have class this morning?"

"Of course we are in class! We skipped class to come and see you. That's not right!" James and Wade were very excited. "Look at the time carefully. It's afternoon now! 5:18 pm!"

Holmes faced the afternoon sunlight that shone into the ward and squinted at the wall clock: "Ah? It's afternoon?!"

Delafield was curious and leaned over to see what he was writing: "What are you doing here?"

"I'm working."

Holmes saw a nurse passing by and quickly stood up and handed her the medical record book he had just written. He briefly said, "The three seriously ill patients all had their gauze changed last night. Mr. Devinck's leg is a little swollen, but there is not much exudate. The general's wife's wound is obviously red and swollen, and there must be an infection. The coachman Fisher..."

"Wait a minute, let me write it down." The nurse took the medical record and opened her own notebook.

Such scenes can be seen everywhere in the ward, and every medical staff is busy serving his or her patients.

After they finished talking, the two found that Holmes had drawn many sketches in his notebook. The drawings showed anatomical structures, marks, various surgical instruments, and the surgical procedures he had written himself, which were very detailed. "What is this? Is he working on it behind our backs?"

"I said I was working. This was the surgery last night. I'm making a note."

Holmes would not hide anything from them, and he knew that he would not be able to hide it, so he openly turned to the pages that had just been drawn about the external fixation of the lower limbs: "How is it? You have never seen this kind of surgery before!"

Janeway and Delafield were silent, completely attracted by the extremely bold yet sophisticated fixation device on the paper: "Are these all fractures? Aren't fractures usually fixed with plaster or amputated directly? Can this kind of thing be used to fix them?"

"Of course, Dr. Carvey tried it last night," Holmes said. "He used the best steel in the world and drilled it into the bone with a thread. Just one needle cost Mr. De Vinck ten thousand francs. The whole leg, not counting the cost of the operation, cost him a hundred thousand francs just for these steel braces."

"What???"

"This is equivalent to a senior official's income for a whole year!!!"

The three of them were considered to have some money in the United States, with an annual salary equivalent to more than 1 francs. After arriving in Paris, they were still shocked by the high cost of living here. The francs in their pockets kept flowing out like water, and they couldn't stop it at all.

Now when I hear about Kavi's charges, it really opens my eyes.

Holmes certainly thought it was exaggerated, but when he thought about the request of Devinke and the general's wife, as the benefit of enjoying the world's first open fracture fixation surgery, the money was well spent. What's more, these two people didn't care about money at all.

"Wait until I finish drawing the remaining surgery before you leave." Holmes picked up the pen and continued writing. "I'm afraid I'll fall asleep in the dormitory and forget some details when I wake up."

This is not an exaggeration. The anatomical requirements of Kavey's surgery are very high, even the best anatomy professors can't compare. Any anatomical detail is enough for him to remember for a while. He took a few bone molds in the surgical storage room, drew and marked them, and finally remembered most of them.

Of course, this was Kavey's standard. In the eyes of Holmes and his two friends, this was far beyond the level of ordinary anatomy textbooks. If it weren't for the fact that Holmes happened to be studying abroad with them, they would have wanted to tear this piece of paper off right now.

"Anatomy diagrams alone are useless; they are only the basics of the basics."

Holmes hadn't slept for thirty hours straight and was really tired, but for some reason, every time he opened the record book, he always felt an inexplicable excitement and couldn't sleep at all: "I drew this based on my memory. This is the position of the arm during surgery. Find the coracoid process, the groove between the deltoid and pectoralis major muscles, and the lateral epicondyle of the humerus and draw a line. The line is the incision location."

"It's such a long incision. Is this the reason why you chose this place as the open wound?"

"I've asked this question before, and it's one of the reasons," Holmes explained. "Another reason is that the fracture is located proximally. This incision is made through the groove between the deltoid and pectoralis major muscles. By pulling aside the muscles and veins on both sides, the humerus can be seen."

"There is a cephalic vein running along the bone at this location. I remember there is also a transverse artery running around the humerus. What is it called?"

“Anterior humeral circumflex artery.”

"Yes, yes, anterior humeral circumflexion." James nodded, muttering anatomical words, "Backward is the posterior humeral circumflexion, forward is the anterior humeral circumflexion, both come from the axillary artery."

Holmes' notes stopped at this page, and he raised his hands and imitated Kavey to perform the surgery: "First, cut the skin and subcutaneous tissue, then free the fascia to reveal the groove between the deltoid and pectoralis major muscles and the intermuscular space between the biceps and triceps. Then enter along the groove and space, toward..."

"Where?" Delafield followed suit.

"Right, right, right. First, pull the biceps inward." Holmes finally remembered the steps, "Then pull the deltoid and cephalic vein outward. Avoid blood vessels when dissecting." James and Wade looked at the picture and asked, "You still don't mark enough. The anatomical structure here is very confusing. To what position should the muscles on both sides be separated?"

"I'm reading this for myself. It's not a real textbook, so of course I only remember the important parts." Holmes thought for a moment, flipped forward on the anatomical diagram, pointed to two places and replied, "To separate the deltoid muscle, go outward to the deltoid tuberosity (the location marked on the deltoid tuberosity), and go inward to the greater tuberosity ridge."

“So it’s this part.”

Holmes then flexed his elbow: "With the elbow flexed, the muscles contracted, and then sharply dissected the insertion of the deltoid and the medial insertion of the brachialis on the tuberosity."

Delafield and James and Wade were both amazed at the precision of the surgery. In order to achieve the best surgical results, every step was taken to reduce damage: "It's so complicated. Just choosing the incision has already used a small part of the muscle anatomy of the entire upper arm."

"Dr. Kavi's thinking is definitely more rigorous and useful than ours."

"What's next?" James and Wade were a little impatient.

"The next step is the highlight." Holmes stopped writing and explained the special situation of the middle part of the humerus. "Because we need to use steel plates and screws, in order to fit the humerus, we need to first understand the shape of the humerus. Look at this cross-section. I drew this piece by piece by myself after looking through the models in the warehouse and the structural diagrams in the anatomy book!"

The cross section of the humerus in the middle section is triangular, which is why the incisions for humeral shaft fractures are generally only made on the anterolateral, lateral, and medial sides. From an anatomical perspective, the anterolateral side hardly encounters too many blood vessels and nerves, making it the most commonly used approach.

According to modern fracture classification, the general's wife's fracture is a wedge-shaped fracture caused by impact, and high-speed impact produces wedge-shaped bone fragments. The bone fragments themselves are free at both ends of the fracture, which is a difficult point in fracture fixation.

Every bit of Kavey's fracture fixation technique was innovative, and every bit of it stimulated Holmes' memory cells, allowing him to remember almost every detail: "Do you know how the humerus is repositioned?"

"do not know."

"Stop being so pretentious and tell me!"

"Unlike the tibia in front, this one is not dislocated much, so Dr. Kawi used forceps." Holmes drew a sketch, roughly outlining what the reduction would look like. "On the sides are the incision retractors, and in the middle are the reduction forceps that Dr. Albaran and I use to fix the fracture."

"Hmm? So what is Dr. Cavi doing?" Janeway asked.

“He is breaking the plate with Director Landreth.” Holmes sketched another picture. “The plate is a long strip with many holes in the middle. In order to fit the anatomical angles of the humerus, it needs to be shaped. They have to use forceps to break out the angles while comparing them, like this.”

"So that's how it is. It has to fit the surface of the humerus."

Holmes suddenly remembered something and picked up a corner of the paper and wanted to tear it off. Just as he was about to do it, he hesitated: "What did Dr. Kavi say at that time? Shaping, pre-bending. Oh, yes! Shaping first, it is indeed necessary to shape first, but the shaping area is fixed at both sides, and a 1mm gap needs to be left in the middle!"

“Why leave a gap?”

"Because there is no pre-bending to leave a gap, when the steel nails are driven into the two sides of the fracture, the other side will crack." Holmes' explanation was not very clear, and he could only touch the outside of his right upper arm with his left hand. "We put the steel plate on the front and outside. If it is not pre-bent, the back side will crack."

"How particular! Can such details be considered?" Delafield and James Wade were no longer sighing, but were doubting, "Such a way of handling details should not appear in the first operation."

"I heard that dozens of these have been done on animals, and it took repeated studies to get this result."

"Oh, no wonder."

"This is too much effort. How old is he?"

"Don't be ridiculous, this is a skill that can be obtained through hard work???"

In this ward, three people gathered together and kept discussing the internal fixation surgery on the humeral shaft fracture that Kavey had performed last night. In the two special wards on the other side of the corridor, Devink and the general's wife Shelly were showing off their hands and feet to the relatives and friends who came to visit them.

"Look, what is the world's top surgical technology? What is the world's first case!!!"

Devin was about to slap his thigh to emphasize the weight of his next words, but before he could do so, he remembered that his right leg had just been reattached, so he suddenly stopped and had to give up: "This is called the world's top technology. Look at these steel nails, sleeves and support rods. Everywhere reveals the hard work of the craftsmen and the unparalleled sense of technology. It only cost 100,000 francs, not only did I save my leg, but I also got to see such technology. It's so damn worth it!!!"

"Didn't you say that to him at that time?"

"Alas! There is no need to talk about the past. I was blind and didn't see the value of Dr. Kavi." Devinke quickly stopped his old friend, the piano dealer Michel Arndt, and said, "Fortunately, it is a blessing that Dr. Kavi is in Paris, otherwise I would have lost my leg!"

"Who says it isn't?"

It was completely different from before the operation. Perhaps it was because of the different fixation methods. Shelly, who was extremely excited before the operation, was now much more reserved than Devinke: "Look at my arm. It has been repaired without any abnormality. It is exactly the same as the one before the explosion. It is amazing!"

Melanie stepped back a few steps, compared them with her fingers, and said with a smile: "It just looks a little thicker. You can't see it at all if you wear loose clothes."

"Doctor Kavi said that there were steel plates and nails inside, so it became like this." Shelly gently patted the head of General Valente who was lying on the bed. "Okay, I'm fine now, and my hand hasn't been amputated. Why are you crying?"

"I, I thought you, you"

"Okay, okay, look at what you look like." Shelly changed her tone, "Go get me the newspaper and see if I'm on the front page! Even if I'm not on the front page, I should at least be on page two. If I had known this would happen, I would have asked someone to take a photo for me."

“Newspaper?” Melanie smiled bitterly. “I’m afraid you’ll be disappointed.”

"what happened?"

Valente wiped away his tears with a handkerchief and told the news he knew: "Last night, everyone was focusing on the explosion at the train station. Some even went to the palace. No one cared about the surgery. Most people didn't even know there was one. This morning, there was bad news again. Now the whole of Europe is in turmoil."

Shelly had just gotten over the dizziness caused by the explosion and anesthesia, and didn't understand what she meant for a moment.

Melanie simply ran out of the ward, found two newspapers for her and handed them to her: "Well, read it yourself."