Nineteenth Century Medical Guide

Chapter 79. 76. The "Empty" Blind Box
Right lower quadrant tenderness and rebound tenderness accompanied by high fever is indeed an important diagnostic basis for appendicitis, but not absolute. 【1】

According to the diagnostic criteria of the modern top three emergency department, the diagnosis must be confirmed by CT plain scan to confirm that there is inflammation of the appendix.If the next-level hospital is more courageous, perhaps a laparoscopy can be performed with only a B-ultrasound.Further down, those small hospitals without surgical operating rooms will choose to transfer to another hospital for treatment.

But in the 19th century, doctors knew so little about intra-abdominal disease that typical symptoms were immediately diagnosed as appendicitis.

The so-called those who don't know are fearless, their judgment is not only fast, but also very difficult to change.In Carvey's impression, Ignatz made a definite diagnosis of appendicitis with a simple press, and made the decision to have an appendectomy immediately.

Without imaging technology, it is impossible for Carvey to see a doctor with as many as 50 differential diagnoses in modern times, nor is it possible to supervise the diagnosis given by Ignatz.Because doctors are human beings, time travel did not give him see-through eyes, even Kawei couldn't make a 100% accurate judgment.

The only thing that can be done now is to cut open the priest's stomach and take a good look at what happened inside.

As Ignatz himself said, the trouble with appendicectomy is finding it.Others such as incision position and intestinal suture have fixed methods, as long as you are proficient, you can do it well. Only looking for the appendix is ​​like opening a blind box, which will give people surprises, frights, or...
Nothing at all.

"We have entered the priest's abdominal cavity. Apart from the thick and greasy fat layers on both sides, everyone should be able to see the bright red intestines. The priest is in very good physical condition, but"

Ignatz's right hand rummaged back and forth in the 10cm incision, but he couldn't find anything: "It's just that his appendix is ​​really hard to find."

Ignatz is also almost 40 years old. Years of anatomy and surgery have made it difficult for his waist to maintain the same posture for too long.Carvey waited tactfully for him to withdraw his hand before choosing to take the offer: "Teacher, rest for a while, I'll look for it."

"Ah."

Ignatz took two steps back to get out of the surgical field of view, then hooked a chair with his toes and sat down, raised his blood-stained hands and quickly continued:
"Although the anatomical position of the appendix is ​​generally in the ileocecal part of the right lower quadrant, there are still many people whose appendix is ​​not fixed in its position【2】. There are many cases of appendicitis, the surgical incision into the abdominal cavity, the appendix is ​​in front of the eyes, and it can be cured after cutting. Close the stomach. But some are more difficult to find, and the priest belongs to the latter.
Ignatz did try his best.

With the poor contemporary knowledge and experience of abdominal surgery, a surgeon who can recognize the variation in the position of the appendix can already be regarded as a T1 surgeon.For other people, once the appendix is ​​not visible after the laparotomy, they will choose to close the laparotomy after searching twice without any results.

After all, misdiagnosis and miscutting are common things, and it is normal to close the abdomen and do nothing. It is better than dying directly on the operating table.As for how to round out the surgical process after surgery, we have to look at the literary skills of those surgeons.

Carvey was well aware of the troubles of acute appendicitis.

The "cheapness" of seeing the appendix after laparotomy is not available every time. Many appendectomy operations take more than an hour, and most of the time is spent on searching.

There is no trick to find the appendix. It is all based on personal experience. The most basic and easiest way to master is to search along the colonic belt of the cecum【3】.

Because the root of the appendix is ​​at the junction of the ileocecal, no matter how it mutates, the root is there.As long as you follow the cecum to find the ileocecal part, you can find the root of the appendix, and then go further to find the inflamed appendix.

So here comes a new question, how to find the cecum?
Ignatz made the mistake of many young doctors in general surgery. He opened his abdomen and went in to see the small intestine full of twists and turns. His scalp was numb and he couldn't find the cecum.If you can't find the cecum, you can't find the ileocecal part. Without the ileocecal part, looking for the appendix is ​​a big project to find a needle in a haystack.

The same mistake, modern young resident doctors are due to inexperience, while Ignatz is limited by the backwardness of abdominal anatomy.

Carvey doesn't like to put his whole hand into his abdomen, which is not something to show off in general.He first shook the priest's stomach back and forth, and after the small intestine followed the mesentery, he lifted a section of the small intestine with his fingers, and his fingertips followed the mesentery to the right and down to its root, where the cecum should be.
However, surgery is always accompanied by various uncertainties. The length and walking angle of this small intestine exceeded Carvey's expectations.

emmm a bit troublesome
Looking at the small intestine slowly moving towards the upper right abdomen, even Kawei, who is used to seeing big scenes, would be stunned.His fingers now follow the mesentery to the upper edge of the incision, but the cecum is not where it should be.

Judging from the anatomical location, we have to look up.

Therefore, in addition to the mutation of the appendix, the human cecum will also mutate, double mutation, double happiness.

"You can't find it either?" Ignatz sighed, realizing that today's operation is a difficult problem, "Let Herman try."

Kavi stepped aside, but didn't let go of his bowels.He stretched out his index finger and pointed to Schmidt's liver area: "I think the priest's cecum is not in the lower right quadrant, but higher up."

"More up?"

Ignatz recalled that he did not see the cecum in the right lower abdomen just now, so he joked to the audience: "Father Schmidt is really a faithful believer in God, even the cecum in his body is trying his best to get close to God's. Sanctuary, admirable."

Perhaps influenced by Hills' departure, he didn't leave his chair, but insisted on letting Herman try.Heman had no experience in abdominal surgery. He rummaged around in the silent atmosphere of the theater and was sweating. He gave up within a few minutes: "Teacher, I really can't find it."

Ignatz understood that today's surgery failure was inevitable, so he planned to search twice more. If he still didn't find it, he had to find a medical vocabulary as an excuse, and shut down his abdomen as soon as possible.

"I think the incision has to be extended upwards."

Carvey would never let them close their abdomens. Ever since they saw a small amount of yellow-green pus mixed with the intestinal tubes after the laparotomy, he decided that it must be an infection.Regardless of whether the inflammation came from the appendix, if there was an infection, the focus of the infection must be removed, otherwise the priest would surely die regardless of whether the abdomen was closed or not.

At this time, the significance of large-scale disinfection before surgery is reflected, and the 15cm range around the incision can be extended at any time.

"If you fail to find the appendix, you should close the abdomen as soon as possible. This is the consensus of the surgical colleagues. If you persist, it may cause surgical accidents." Ignatz persuaded, "Little Schmidt and the monks and nuns of St. Mary's Church are all here. The news of the operation is waiting outside the theater, it is too ugly to let the priest die on the operating table."

"But you can't get rid of the lesions by closing the abdomen, and you will die sooner or later." Carvey glanced at the saliva that had dried up at the corner of Schmidt's mouth, and said, "Give me some more time, I want to try again."

Ignatz was calm: "You can also think about it from another angle. Maybe we misdiagnosed it. The priest does not have appendicitis."

Carvey:? ? ?
Isn't this just shaming?
Carvey shook his head, picked up the scalpel, and handed the handle to Ignatz: "Whether it is appendicitis or not, we have to catch it before we can make a conclusion, but I firmly believe that the teacher's diagnosis is correct."

This made Ignatz feel relieved for a while.

"I'll just listen to you once." Ignatz stood up and picked up the scalpel again, "Everyone, since the cecum of the priest was not found in the entire right lower abdomen, the appendix is ​​very much like a prisoner who has disappeared without a trace. .We now need to extend the incision upwards by about 5cm to cut more muscle, fascia and peritoneum, and then expose more of the small intestine.”

Carvey stared at the small intestine in his hand and continued to search up the mesentery.At the same time, he did not hang himself on a tree, but used another method to find the cecum, lifting the outer peritoneum and looking inward along the outer peritoneum. 【4】

The two directions went hand in hand, and soon there was a result: "Teacher, there should be the cecum of the priest in front."

It was less than 2 minutes after the incision was enlarged, and Ignatz was surprised and delighted by Carvey's discovery: "What a surprise, it seems that my diagnosis is not wrong. The priest is a very typical appendicitis. Here is the cecum, and the next step is The ileocecal, where you can still see the yellow-green pus."

For a small amount of pus encountered in the abdominal cavity, modern surgery will use a suction device for temporary treatment. If a pus cavity or perforation is found, it is necessary to wash the stomach with a large amount of normal saline during the operation.

In the 19th century, it was much simpler. Because there was no high-power suction device, many surgeons regarded it as if they hadn’t seen it, let alone deal with it.

The pus accumulated in the body may continue to cause inflammation, or infect the surgical wound, making the entire operation futile.

Carvey didn't speak. It's not wise to interrupt the operation now, so he took two clean gauzes and quickly wiped off the pus while Ignatz was looking for the ileocecum.While simple wiping is not as clean as washing with water, it is also a way to prevent the spread of infection.

Ignatz didn't notice these small movements, his attention was all on the ileocecal he had just found.

Part of the cecum is fixed to the peritoneum, and the free part can see the connected ileum, where the three colonic bands converge, and here is the root of the appendix: the ileocecal.However, in the eyes of everyone, this is a messy mass of meat, and the appendix that should be connected to the end of the ileocecal is missing.

Ignatz bluntly dissected the cecum in amazement, and was really speechless: "This is really surprising, the priest's appendix is ​​gone!"

After hearing this, the venue was full of doubts, and the food in their hands suddenly became tasteless.A patient who needed an urgent appendectomy had no appendix in his body.And it wasn't that there was a mutation of the appendix, nor was it that there was a problem with the technique of the main surgeon, but that it was really impossible to find.

Even Varela, who had seen many foreign surgeries, dropped his jaw in shock, and couldn't help but say to himself: "This should be the ileocele, there is no reason why I can't find the appendix."

"Did I go to the wrong place?"

Ignatz smiled and doubted himself for a moment, then compared the intestines in his hand back and forth.After confirming that it was undoubtedly the ileocecal part, he unceremoniously expressed his opinion: "The appendix has indeed disappeared. This may be a brand-new visceral variation, the natural appendix is ​​missing!"

In front of him is Ignaz, the chief surgeon of Austria. His explanations and operations are textbooks, and the audience can easily accept them.

Since the appendix is ​​missing, there is no other way but to end the operation. Originally, ether anesthesia is unstable, and no one knows when it will fail.

Half a month ago, due to insufficient anesthesia, Morazo almost ruined the operation when he woke up halfway. The chaotic scene was still replaying in Ignatz's mind. He didn't dare to take risks: "It seems that the priest is not appendicitis."

Herman was already preparing needle and thread beside him: "Shut up now?"

There is no appendix in an appendectomy, so it's better to end such absurd operation as soon as possible.Closing the abdomen was Ignatz's original intention, but when he was about to nod, Carvey suddenly interjected: "Teacher, I also think this is a mutation, but the appendix is ​​not gone, but hidden deliberately. "

"Hidden? What do you mean by hiding? Where is it hidden?" Ignatz didn't understand what he meant, and pointed to the ileocecal area and said, "The root of the appendix should be in the ileocecal area, and there is no way it could go anywhere else."

Carvey knew that it was useless to say the result directly, so he simply pointed to the candle lamp in a nurse's hand: "The brighter the place, the easier it is for darkness to accumulate and hinder our sight. I think the appendix is ​​attached to a certain place around the cecum. place, camouflaging itself with the serosa layer on the surface of the cecum."

Pasted around the cecum?

Disguise yourself with serosa?

These explanations have greatly exceeded the cognition of everyone present, because no one has ever mentioned: "Dr. Carvey, you are not joking."

"You mean the cecum swallowed the appendix?"

"This is so strange, how can there be an appendix in the cecum?"

This is a special variant of the appendix: the cecal subserosal appendix. 【5】

Not to mention that Ignatz doesn't know it, even the top surgeons in the world don't know it. This is a modern professional term.Of course, Carvey couldn't just say the name directly, because no one would believe it even if he said it.

The audience's trust in Carvey came and went quickly, it was cheap, and there was no substantial difference. All Carvey wanted was the trust of Ignatz, the absolute authority in the entire surgical theater: "I'm sure it's inside the cecum, as long as You can find it by opening the serosa layer here."

"Cut the serosa layer? Surgery needs to avoid accidental injury as much as possible, but you let me take the initiative to injure a non-surgical site?"

"The lumen of the cecum is very large. Even if the serosa layer is really injured, it can be repaired and there will be no major problems."

"What about anesthesia?"

"It's the same way as Earl Moraso's at that time, not to mention that the priest is sleeping soundly now."

Holding the scalpel in his hand, Ignatz was still hesitating: "You have to find its exact location before I can consider whether to free it for further resection."

"Positioning is not difficult."

Carvey tightened the serosa on one side of the cecum, touched back and forth with his fingertips, and quickly found the appendix hidden in it.Even if its appearance has changed, the touch of the operation that has been accumulated over the years is hard to change: "Teacher, if I guess correctly, the appendix is ​​here."

(End of this chapter)