These days, Kawei's focus is on experiments, and he wants to get experimental data as soon as possible to support his medicine before Nora's cesarean section. But he did not ignore the patients in the ward. He was there every day for ward rounds and never stopped observing after surgery.
Of course, it's just observation.
Kawi has taken over or indirectly taken over five patients. Except for Laszlo, who has completely recovered, and Morazo, who has improved a lot, only Eston, Mrs. Gale and Alphonse are left to rest in the ward.
The sutures were removed from Mrs. Gale's lip seven days after the operation. The wound has already healed, but it will take some time for the swelling to completely subside. Although Alphonse's butt has not completely healed, it is growing well, at least it does not have ulcers like other post-operative patients.
Ignatz has already discussed the idea of a new cleft lip surgery with Mrs. Gale, and only needs to perfect a few details before it can be used on Mrs. Gale's children.
Among them, the most gratifying thing for Kawei is Eston. After half a month of rest, the swelling in his calf has subsided and the wound has healed well. It was unimaginable in the medical environment of the mid-19th century that sutures with such a long distance and multiple stitches could remain completely ulcer-free.
And Eston's fracture is also developing in a good direction.
There is almost no displacement of the fracture. From the appearance, both lower limbs still maintain symmetry, the broken ends should be well aligned, and there is no neuromuscular damage.
This means that as long as Eston continues to lie in bed for a period of time and insists on rehabilitation training, he will have a pair of calves as strong as other people of his age when he is discharged from the hospital.
At this point, Kawei welcomed his sixth patient after time travel.
Fernand, a 29-year-old butcher who sells meat, suffered from severe bladder stones, which not only caused severe pain, but also caused annoying urethral obstruction. The reason for seeking medical treatment is that he hopes to be able to get rid of the pain once and for all and directly relieve him from the pain that is worse than death.
After a brief examination, Ignatz found that in addition to the symptoms of stones, Fernand was also dissatisfied with the appearance of the penis itself. This dissatisfaction breeds strong anxiety, which seriously affects his status in the family and marital happiness.
Ignatz remains conservative on circumcision.
However, after considering hygiene reasons, he decided to comply with Fernand's wishes and made a complete surgical plan: first perform lithotripsy, and then perform further circumcision.
This slightly disrupted Kavi's pace.
Because intracorporeal lithotripsy does not require body surface disinfection, only the instruments must be disinfected. Circumcision requires very thorough disinfection, otherwise ulceration will occur in such a critical part, and the consequences will be disastrous.
And there is no need to bandage the broken stones in the body, but the bandaging after circumcision is very particular...
"Don't be too surprised. This is the preoperative preparation that my assistant Mr. Kawei has constantly improved. Before, alcohol and alkali soap were used, but now a more special thing, bleaching powder, is added. In addition, there are also Gauze, cotton bandages cooked at high temperatures, and ointment used to cover wounds after surgery.”
What Kawei brought into the surgical theater was a complete set of medicine bottle boxes and dressing storage boxes [1].
In addition, just like the laboratory, he also brought several wash basins to hold disinfection supplies.
There were many current medical students and surgical colleagues in the theater, and handwashing generated a lot of discussion. But after Ignatz described the recent conditions of the five patients, regardless of whether they had any grudges in their hearts, they finally chose to remain silent.
"I don't think what happened to these five patients was a coincidence."
Ignatz also followed Kawei's example and disinfected his arms in turn:
"This is very rare in surgery where the chance of wound ulceration exceeds 50%, even to the point of being almost abnormal. Especially the recovery situation of Count Morasso's inguinal hernia surgery. It is difficult for me to use one or two words to describe everything these days. If there are any changes, I will publish an article about this surgery in the Vienna Medical Journal.
Before that, I still hope that you can show as much scientific curiosity and desire for exploration as possible, and be more encouraging and tolerant of this young man's attempts to actively explore the boundaries of surgery. After all, science is full of chance, but once chance becomes inevitable, it will take surgery to a deeper level. "
The effect of disinfection, coupled with the new cleft lip repair procedure that was sent before, earned Kawei the endorsement of Ignatz.
With his endorsement, Kawei’s unique disinfection method was completely recorded in the record books by many viewers. Of course, many people will put a question mark next to it, and there will also be people who will directly draw a cross, but based on the principle that black and red are also red, being remembered is a kind of progress.
Apart from being a bit pungent, alcohol and bleaching powder didn't have many drawbacks. They made some complaints before entering the actual surgery.
“Since the 18th century, surgery has made amazing progress, surgical methods have been constantly innovated, and surgical instruments have been constantly updated.”[2]
Ignatz took out a set of surgical instrument boxes related to the urinary system [3], opened the flip cover, and took out a long curved tube [4]: "To deal with huge bladder stones, we have been using methods that were still popular in the 18th century. Lithotomy, from the early lithotripsy more than 20 years ago, can now achieve precise lithotripsy..."
"Teacher, can I ask a question?"
"Excuse me."
“What method was used in the early days of gravel crushing?”
Ignatz smiled and shook the metal urinary tube in his hand, "It means rotating the tube at high speed and using the hard end to hit the more fragile stones. The process is painful, but it is better than nothing." Lithotomy under anesthesia is much better.”
"That's it?" The student put his hands together and made a gesture similar to a spinning bamboo dragonfly.
"Yes, rub it quickly and repeatedly to make the curved end swing."
"..."
"It was indeed a bit rough, so we quickly came up with a new method, which I will describe in detail later. For now, let's help Mr. Fernand guide the urine that has been stored for most of the day... ..”
Kawei lifted up Fernand's little baby, and Ignatz slowly inserted the catheter into it: "When using this kind of catheter, you will definitely encounter resistance from the urethral wall. At this time, you can consider Use an ointment mixed with essential oils to lubricate the wall of the urethra, which not only reduces resistance but also reduces damage to the urethral wall.”
While speaking, the front of the catheter encountered some resistance.
Seeing this, Kawei straightened the baby as much as possible to reduce the curvature of the urethra. With the lubrication, the resistance was quickly overcome and the tube entered the bladder smoothly.
Ignatz looked at the gurgling yellow urine and couldn't help but said: "Although Mr. Fernand has already fallen asleep, I still have to congratulate him here. The catheterization went smoothly and no bladder puncture was needed. "【5】
Fernan's urethral obstruction lasted for a long time, and the urine output should have been more than 1,200 ml.
In the 19th century, there was no limit on the amount of urine that could be catheterized [6]. Carvey also knew that once the bladder bleeds, it would be considered an inadvertent bloodletting, which would become an advantage in the process, so he did not say much.
"Very good, bleeding after catheterization." A smile appeared on Ignatz's lips, "The operation went very smoothly, and God is also helping Fernand."
Kawei took out from the side the urethral dilation tube he had found from a device company to make a new one (see 17-2): "Teacher, No. 6?"
"It's not enough, just give me the biggest one."
Ignatz smiled and took the No. 12 dilation tube and continued: "Although the original plan is lithotripsy, in order to be responsible for the patient, we still need to try to remove the stone first. If the stone is really too big, We will choose lithotripsy as a last resort, after all, broken stones can cause damage to the urethral mucosa."
In fact, urethral dilation is inherently an injury. Due to the inflammatory response after injury, this type of dilation will only aggravate postoperative urethral stricture.
It may be that the inflammatory reaction caused by the urinary tract infection in Fernand stimulated the urethra and caused stricture in the first step. The narrow urethra would further put him in a state of chronic urinary retention. Over time, the urine retained in the bladder forms a large number of crystals, which eventually solidify into stones.
But there was no way. It was impossible for Kawei to tell Ignatz such a lot of truths that he couldn't understand on the operating table. Everything had to be done slowly.
Take the stone [7] first, and if it gets narrower, we’ll talk about it later.
However, the stone removal process was not smooth. Even with the thickest No. 12 dilation tube, Fernand's urethra was still unable to bear the huge size of the stone, and in the end, the stone had to be broken up in the bladder.
Depending on the size of the bladder stone, the instruments used for lithotripsy vary slightly.
If it is a small stone, there are lithotripsy pliers [8] in Ignatz's box. Because the jaws need to be opened before they can be used, there are certain limitations. If it is a large stone and the jaws of the lithotripsy forceps are not large enough, you will need to use something larger.
Without B-ultrasound, no one could estimate the size of the stone. Considering that large instruments would cause certain trauma to the urethra, Ignatz chose to use forceps first.
It must be said that Kawei’s homemade ointment helped a lot during this operation. Continuously and repeatedly moving in and out of the already narrow urethra did not produce much resistance, and Ignatz used it very smoothly.
This smooth feeling will be fed back to the surgeon, making him more relaxed and the surgery will become more comfortable.
"Kavi is ready, help drag the two little things...Okay, I seem to have caught one, it's quite big." Ignatz's posture was like pinching briquettes, with both hands Holding the handle of the pliers tightly with his hand, he heard a crisp sound and closed the pliers, "I'll look for anything else and crush these small ones by the way."
Kawei knew very well that if it was just a small stone, it would not be enough to make Fernand suffer so much.
If Ignatz could do some palpation of the lower abdomen with his hands, he should be able to estimate the size of the stone, but unfortunately he did not. Just like those physicians, Ignatz also regards as much as possible not to touch the patient before surgery as the criterion for a doctor's superb skills.
He prefers direct observation to touching with his hands, so this kind of "downgrading" thing still has to be done by Kawei: "Teacher, his bladder is so hard."
Ignatz looked up at Kavi, and his hand "happened" to be placed on Fernan's lower abdomen: "Can you feel the stones here?"
"I don't know if it's a stone." Kawei gave up his position and gave a gift in return, "It just feels different from a normal person's lower abdomen. After the teacher said this, it does feel very similar."
These words were suspected of being flattering. Although they were of no use, Ignatz listened to them.
After emptying the bladder, the shrunken bladder wall wraps around the surface of the stone. With a little bit of force, the stone can be felt. The volume has exceeded the clamping range of lithotripsy forceps, unless the urethra can be dilated to the thickness of two fingers.
"It's too big... Let's replace it with a new set of gravel crushers."
What Ignatz is talking about is a fixed pressure crushing device. Unlike the lateral force exerted by the lithotripsy forceps, this device exerts longitudinal pressure on the stones. Because the force is longitudinal, there is no need to expand the urethra, but the source of the force is slightly different from that of lithotripsy forceps.
"Everyone, to be honest, I don't really want to use it." Ignatz reluctantly took out a long metal rod with inner and outer main and auxiliary rods and a small hammer from the box. "A man from the UK A masterpiece of a master of lithotripsy, it can not only easily clamp large stones, but also exert a force at the tail end to shatter the stones."[9]
The instrument is very long, and in order to increase the transmission of force, there is no strong locking device at the end, so Kawi and Ignatz need to work together to fix it.
"Okay, clamp it. This stone is definitely one of the top three in my many years of career." The two of them held the handles on the left and right. They still needed to judge the position of the stone before breaking it. Reduce the pressure on the bladder wall, "Move it out a little more, okay, this position is good!"
Ignatz turned sideways and held the hammer steady: "The next step is gravel. In order to protect the patient's delicate internal structure, this will take some time. Because I heard that in the UK, where it originated, the operator used too much force. It even caused a perforation of the patient's bladder, so it was very dangerous to use."
Then, a rhythmic percussion sound floated throughout the theater.
Don't do it too fast or too hard. Let the impact fall on the stone and dissipate around it as quickly as possible to reduce the impact on the bladder.
When~when~when~......
Crushing stones has always been a delicate job, and Ignatz had to restrain the urge to crush the stones as quickly as possible without making the stones too easy to break. Choosing the strength of his hands required both experience and talent.
Even a surgeon like Kawei would find it difficult to completely control the force without using it before.
Maybe this sound is too distinctive, or maybe it’s the musical cells in the Vienna people that are at work. As soon as the stone crushing process started, you could hear some echoing voices in the theater, and then rhythmic applause joined in.
Until the end, the operation scene turned into a short concert, and even Ignatz himself was led astray. Some hints of Beethoven's Symphony of Destiny could even be heard in the percussion.
"Everyone, the stone is broken~"
