Tuberculosis can be found anywhere, so before the 19th century, doctors had no idea what kind of disease it was. It was easily confused with other diseases, and there was no word for it. For example, cutaneous tuberculosis is called lupus vulgaris, pulmonary tuberculosis is called consumption, and spinal tuberculosis is called Pott's disease. 【1】
It wasn't until scientists discovered during anatomy that there were solid masses in the lungs of such patients, which felt like tubers on plant roots, that the disease was called Tuberculous (tuber means tuber, and culous is the adjective suffix). . 【2】
Compared with the extremely straightforward naming method in English, the domestic translation is more literary and artistic. It is "tuberculosis", which is like the "hard knots" and "small nuclei" in the human body. It can also be understood as "hard nuclei". .
The patient's abdominal cavity is full of these small white nuclei, which can be seen at a glance. Such typical cases of tuberculous peritonitis were common when Kawei was young. However, as domestic anti-tuberculosis treatment became more and more perfect, such patients became increasingly rare, and they did not even have the opportunity to use them as teaching materials for students.
There are very, very few people who really understand and are familiar with tuberculosis, and some people have never even heard of the word tuberculosis. But if tuberculosis had to be given another title, they must have heard it before, and it would be the "White Death".
"Dr. Carvey, what did you just say? What about peritonitis?"
The assistant beside him explained: "I heard it means 'potato tuber peritonitis'..."
"It's tuberculosis, the commonly seen white plague, also known as the White Death." Kawei explained briefly, then changed the topic, "There are many doctors and medical students present, and I think tuberculous peritonitis is more appropriate. .”
The audience was now in chaos because of the sudden gush of ascites and the pronoun synonymous with tuberculosis shouted by Kawei.
Hills in the audience knew what "tuberculosis" meant. It was taught in medical school, but he just mentioned it casually without going into details because no one understood it and it was impossible to talk about it.
The research papers on tuberculosis in cutting-edge medicine did not start to explode until after 1875. Before that, they only appeared sporadically [3]. Fortunately, Hills is a surgeon and has been accompanying Ignatz to dissect corpses. He often encounters tuberculosis patients and knows very well that the growth of white globules in body tissues is a typical pathological change of tuberculosis.
but......
"Can tuberculosis grow in the abdominal cavity?" Hills drained the ascites and then took out the mesentery and omentum, which had thickened due to inflammation [4]. Looking at the dense tuberculosis lesions, he couldn't help but said to himself: "It's really terrible..."
"That's a guess on my part."
After hearing about Semmelweis's hand-washing and attending the regular meeting of the College of Surgeons, Kawei now became very cautious and was not in a hurry to throw out the definition: "But I did have the honor to see a similar case, the same abdominal pain, the same He had a cough, was equally weightless and had ascites, and what he saw after the incision was the same horrific sight."
"Have you seen it? You are only 17 years old!" Someone in the audience was "dissatisfied".
"It was when I was a child." Carvey still put all the reasons on the head of a non-existent rural surgical barber in Lombardy. "My adoptive father died early, otherwise he would have published a series of surgical books for reference in his later years. It’s an eye-opener for everyone. I learned part of my painting skills from him, which is great.” [5]
There was a lot of discussion on the stage, but Hills stood alone by the operating table in the audience, not knowing what to say: "You...do you have any evidence?"
"These small nodules in Mr. Edward's abdominal cavity are very similar to the nodules of pulmonary tuberculosis. Any surgeon who has participated in the autopsy of a tuberculosis patient will remember the characteristics of this lesion." Carvey explained, "In addition, pulmonary tuberculosis Pleural effusion will occur, and ascites will occur with abdominal tuberculosis, which is exactly the same."
In the absence of a series of complete theoretical and testing foundations such as bacteriology, microscopy, and tuberculin testing, symptoms and lesion morphology have become the absolute standards for diagnosis.
However, these remarks by Carvey are more like speculation and cannot convince everyone, and Hills is one of them.
This was the first operation after leaving the Municipal General Hospital. He wanted to declare his "independence" with absolute victory, so he declined Kawei's request before the operation. Now he also declined Kawei's suggestion: " Dr. Kawei, the reasons you mentioned still fail to prove your point of view."
"I know that the evidence in my hand is still very weak, and it is more just speculation. Calling it 'tuberculosis' directly is still open to question." Carvey suggested, "But since the patients I saw when I was a child are so similar to Edward, I feel that I I have an obligation to remind you.”
"Remind me?" Hills began to prepare for cleaning: "Remind me of what?"
"My father's patient not only had tuberculosis in his abdominal cavity, but also in his intestines. Those tuberculosis balls happened to block the intestines, which caused severe pain and constipation..."
Kawei looked at the operating table and sighed, and said: "Tuberculosis is too troublesome. It has a wide range and many lesions. As long as the constipation can be cured, it will be fine."
If we follow the treatment methods of modern medicine, medical treatment will be the main treatment for Edward's situation. Because the best way to fight tuberculosis is always those anti-tuberculosis drugs, surgery can only treat some organic lesions that cannot be changed by drugs, and cannot play a decisive role.
The causes of abdominal pain and intestinal obstruction caused by tuberculous peritonitis are different. Some can be relieved by surgery, while others can only be closed conservatively. 【6】
If Kawei's instructions were followed, Hills would only need to use a needle to drain the ascites, and there would be no need to open the abdomen. But now his stomach has opened, just like a watermelon that has been opened and cannot be closed. He has to do something, otherwise it will be too embarrassing in public.
Surgery can continue to focus on "exploration", closely following today's theme.
There are only three things to look for, one is whether there is accompanying intestinal tuberculosis, one is whether there is adhesion between the mesenteric omentum and the intestinal tube, and the other is whether there is ulceration of intestinal tuberculosis. Edward has abdominal pain and intestinal obstruction, so one of the three must be there, and that one is the target of this operation.
Regardless of whether he is the real mastermind of tuberculous peritonitis or not, let’s kill it first and show it to the audience first.
Intestinal adhesions cannot be managed [7], so the goal is very clear to find intestinal tuberculosis. Hills only needed to avoid those miliary intra-abdominal dissemination lesions, find the mass in the intestine, no matter what it was, cut it out and perform an intestinal anastomosis to end this difficult operation.
The operation was a bit more difficult, but Hills had at least been an assistant in Morasso's operation and had seen Ignatz's intestinal suturing.
If done well, Edward's tuberculosis will definitely not be cured, but his constipation will be relieved a lot. If it doesn't work well, then Kawi has no choice but to ask for his own blessings.
But Hills is a strong person after all, and his willingness to give up his position at the Municipal General Hospital has already shown his determination. He felt in his heart that Kawei might be right, but he couldn't agree with his mouth: "Dr. Kawei, do you mean to let me ignore these crazily spreading lesions?"
"If you can't control it, you might as well cut off all the diseased tissue."
Hills looked at the thick omentum in his hand and said firmly: "Forget about the intestinal wall, but the affected omentum and mesentery must be removed."
Kawei: "..."
"Thank you Dr. Kawei for your reminder and advice. Although I feel it is not very helpful to me, I still thank him sincerely."
Hills snapped his fingers to his assistant and then made a skin incision: "Because there are too many lesions in the patient's abdominal cavity, I decided to expand the incision and remove these lesions by their roots. I can't judge the extent of the lesions yet. So I can’t give you the exact surgical method..."
Although Hills has a tough talk, he also learned a lot from Kawei. At least his hands during the surgery were honest.
Soon, Edward's body was covered with a layer of gauze, and the soft tissues in his body were taken out of the abdominal cavity and lay quietly on the gauze.
The workload of removing these meso-omentums is huge, and just dissociating them one by one is already very time-consuming, and it is not something that a doctor of Hills' level can do. Even if Ignatz takes over, he will still feel a headache when he looks at a large piece of soft tissue that cannot be distinguished from east to west.
But in terms of difficulty, this operation can be considered a success.
"This is the first attempt in history." Varela, who was sitting behind Kawei, was very excited. "It's a total omentectomy + total mesotomy. It's so impressive."
Kawei shook his head and muttered under his breath: "It's meaningless if the patient dies."
"You can't say that." Varela seemed to have heard what he said and stepped forward and said, "Caesarean section is difficult enough and the mortality rate is high enough, but since it was invented, surgeons have chosen to try it one after another. .”
"That can't be helped."
"The patient has unbearable abdominal pain, and there is nothing we can do."
Kawei looked back at the reporter who was arguing with him and chose to remain silent. However, before he remained silent, he still replied: "From what you put it, surgery is actually simple. Just cut wherever it hurts."
Varela strongly agreed with this sentence: "Yes, isn't this the meaning of the existence of surgery?"
"Does that headache hurt?"
"Head..." Varela was about to answer but choked back, "Forget it, I'll continue watching the surgery. This surgery is more interesting than the amputation that lasted more than half an hour."
The surgery took longer than anyone expected, even Hills, except of course Kavey. The workload is so huge and the surgeon is not very skilled yet, so the speed of the operation cannot be increased at all.
"The Romance of Fairy Wood"
After all, it was Haikou that he boasted about, so Hills had to bite the bullet and complete the operation.
The audience on the stage also bought tickets. They were seeing a technique they had never seen before. Although the process was boring and the explanations were sparse, after all, they bought tickets to enter the theater. If you don’t watch it, you will always feel that you are at a disadvantage.
No one in the entire surgical theater wanted to give up halfway, but the patient didn't have that much thought.
"Teacher Hills, the patient's hands are moving."
"Press him down and give him ether quickly." Hills pinched a ball of tissue. "The operation is almost over. Don't let him wake up."
"good."
The assistant turned around in a hurry, went back and took out the ether anesthesia equipment he had just used.
Pour a certain amount of ether into the container, then place the mask on Edward's mouth and nose. After the slowly evaporating ether gas enters the patient's airway and then diffuses into the brain, the anesthesia will be successful.
"Cough cough cough~~~"
Edward had a violent cough, but fortunately he had a mask to cover it, so the scene wasn't too bad.
"What are you doing?" Because of the violent shaking of his body, Hills had to stop the knife in his hand and turned to hold down Edward's body with his assistant. "Is the anesthesia ready?"
"I, I don't know either."
The assistant, who had just graduated from medical school, looked very flustered. This was the third operation in his life, and the first anesthesia in his life: "I did it according to the method you did before. After watching him breathe five or six times, he should be under anesthesia. But..."
There was another violent cough, and Edward, who was half asleep, bounced up slightly and spat out another large mouthful of blood.
"Get the gauze quickly!" Hills was very dissatisfied with the anesthesia effect. "And you, wipe the mask clean and put it on him quickly!"
The assistant didn't dare to say anything and quickly followed the instructions.
The effect of ether finally suppressed the irritation of coughing in the lungs, and Edward lay quietly under Hills' scalpel again: "Today's surgery was full of twists and turns. There was a little accident just now. Now my assistant has done it again. After the anesthesia is done, the operation will continue."
Hearing this sentence, many viewers breathed a sigh of relief. For them, they had passed a hurdle with the chief surgeon.
The surgical theater has returned to calm, but the tense and exciting atmosphere has not completely subsided. The operation has entered the final stage.
"Teacher, you don't even try to persuade him."
Kawei couldn't stand it, but he still hoped that Ignatz could help him say something: "The patient is so thin, and he had hemoptysis just now, so lying down like this is not an option. And even if the operation is successful, the patient's body can't keep up. I’m afraid I won’t live long.”
"Do you think he can listen to the advice?" Ignatz shook his head, "It's almost over anyway, let him go."
The operation continued with the joint efforts of Hills and two assistants. Kavey, sitting in the second row, could only barely see some suturing and knotting operations, and many fine anatomical details could not be clearly seen. Sometimes the surgical images are temporarily missing due to the obstruction of the doctors’ limbs on the stage.
At this time, Kawei could only guess the progress of the operation through their facial expressions and movements.
The expressions of the three people before were all very natural. Although they were occasionally nervous and solemn, the overall expressions remained on a relatively stable baseline. But when the operation was about to come to an end, the assistant who had just administered anesthesia to the patient suddenly became panicked.
He was very nervous, so nervous that he felt at a loss. He was even more nervous than before when the anesthesia was not sufficient.
Kawei was a little curious, and looked at his hands. One hand was helping to retract the hook to maintain the surgical field of view, while the other hand was placed on Edward's arm, as if measuring his heart rate and pulse. Looking at the patient at this time, he was very quiet. Apart from his open belly, only the blood stains from the hemoptysis and a pile of pink foam remained around his mouth.
"teacher."
Ignatz, like other viewers, stared at the central surgical area: "Huh? What's wrong with you?"
"Look at the patient quickly."
"Patient? Didn't the patient sleep well?"
"I feel like the patient is dying."
