[The editor said that the chapter I had swallowed before would be released in a few days. You should wait a little longer, otherwise it will be duplicated and deleted and it will be more troublesome]
The patient this time is fundamentally different from the previous one.
Ludwig was an Imperial Marshal with a distinguished status, and the surgery was performed on a very delicate part of the spine, close to the central nervous system, the spinal cord.
The operation is related to his later life, and if it is successful, it can cure the pain in his waist and legs that has lasted for ten years. However, if performed improperly, although it will not cause paralysis, it will seriously affect the stability of the spine. Some failed operations will worsen the original pain symptoms until all sensation in the area responsible for the nerve disappears, and the postoperative hematoma will also produce severe compressive pain.
These are actually complications of surgery. In order to protect himself and gain decision-making power during the surgery, Kawei and Ludwig must sign a statement similar to an informed consent form.
"Mr. Butler, please read carefully. It is clearly written here that 'during the anesthesia of Mr. Ludwig von Benedek, all matters related to the operation will be solely responsible for all matters related to the operation.'" [1 】
Kawei pointed at the last signature of the old marshal with his finger: "It's written in black and white on the paper. You watched him sign it."
The butler was aware of this statement and was actually present in the drawing room last night.
However, his understanding of the statement was limited to the medical aspect, and he never thought about other aspects, let alone why he had to take off his pants for waist surgery. For the current head of the distinguished Benedek family, being stripped naked by a pariah and placed on the bed like a fan of pork waiting to be slaughtered was not only indecent, it was simply an insult to the entire family.
"I have accompanied the master on the battlefield before. I was injured in many places and suffered a surgeon's knife. I have never seen such an operation." The housekeeper rolled up his sleeves and lifted up his shirt, revealing several scars. "If you do this, You are bringing shame to the Benedek family!”
"Forget it, old housekeeper, surgeries now are not as good as they were back then."
Seeing the tense situation between the two of them, Waterman ran out to smooth things over: "To be fair, Dr. Kawei's actions are all based on the health of the marshal. From a medical point of view, there will be no problem."
"Does that mean that there are problems if you think about it from other perspectives?"
"But we are in surgery now!"
Waterman didn't know what kind of medicine the old man took wrongly, and why he kept staring at taking off his pants. But one thing he was sure of was that the old housekeeper would never do anything detrimental to Ludwig: "The ether has already taken effect, and we are in a hurry. Secondary anesthesia will be very risky. If there is any problem, wait until the operation is over. Let’s discuss it further.”
At this point, the housekeeper finally gave in, but he still couldn't swallow it. After cursing for a while, he and the two maids took off the marshal's pants.
If it had been a week ago, he would never have had this attitude towards Kawei. He would have felt the same as he did towards other doctors. In addition to necessary respect, it is also recognition of Kawei's technical ability. After all, there are so many outstanding doctors on the field working on him.
To be able to perform surgery in front of so many people, my skills must be unparalleled. Even if there was a misunderstanding about disinfection and undressing, it was a matter between Kawei and Marshal Ludwig. He had no need or qualification to stand up and make irresponsible remarks.
What really made the housekeeper feel unhappy was Fernand's surgery.
Fernand killed Albert, whom he had watched grow up, and Kavi saved Fernand. The transfer of disgust was so simple.
"If you had to choose between 'reviving a death row prisoner' and 'demonstrating surgical skills,' my attitude towards that operation would definitely fall into the latter category." Kawei explained, "If you really want to find someone to vent your anger, I I think we should go to Mr. Edouard, the French ambassador who has not agreed to the execution so far, and those fanatical fans who send letters to the murderous maniac every day." [2]
In a nutshell: [I am only responsible for the surgery and don’t know anything else]
Kawei also did not expect that the results of this portal hypertension surgery would go far beyond the scope of medicine.
The final curtain call was not completed, and such a big mess was caused. In addition to reflecting Edward's conflicting psychology at this time, it also reflects some people's pursuit of simple sensory stimulation. As for the affirmation of medical progress, I'm afraid it's not at all. 【3】
It was outrageous, but Kavi wasn’t too surprised.
Abnormalities exist in all eras.
After listening to Kavi's explanation, the housekeeper had nothing to refute and was busy taking care of the cushions on the operating table: "So this confirmed murderer is at large? Just because of a Frenchman? Just because of those letters ?”
Kawei didn't know what Edward was hesitating about. He just felt that it was not difficult to get things done: "Just wait, the Frenchman will definitely find a way to solve all this."
housekeeper:"???"
"Okay, next we have to disinfect the bedroom." Kawei opened the door, "You guys are waiting outside the door. If there is a need or the operation is over, I will tell you as soon as possible."
After solving the portal hypertension for Fernand, Kawei invited the chief doctors in front of him to "explore" the cause and treatment of low back and leg pain. It took him five days to convince the four people in front of him of the diagnosis of lumbar disc herniation.
Marshal's pain is located on the right side, at waist 4-sacral 1.
Modern lumbar discectomy has entered the minimally invasive era, with small incisions, less bleeding, fast healing, and fast recovery being synonymous with it.
Unfortunately, Carvey was unable to do this. He chose the most classic lumbar discectomy through the posterior midline approach, which was reported by Mixter and Barr in 1934 to treat sciatica. It was also the first lumbar discectomy in the world. 【4】
The operation is not difficult. After all, it is a simple resection that has been carried out for decades. It has undergone a lot of optimization. As long as you follow the procedure, there will be no problems with the operation specifications.
But before the surgery, there was a troublesome issue: positioning.
The location of the vertebral body under imaging examination is very clear, but on the operating table, without a C-arm X-ray machine, the doctor can only do body surface positioning. The body surface positioning of the lumbar vertebrae is not easy. Only one of the five vertebrae is basically fixed, and that is the space between L4 and L5, which is the spinous process of L4.
Fortunately, the area of this operation, from waist 4 to sacrum 1, is large enough and happens to cover this location.
"From the autopsy examination, we can know that the space between the spinous processes of Lumbar 3 and Lumbar 4 happens to be located at the line connecting the highest points of the iliac crests on both sides." Kawei made a simple measurement and selected the starting position of the knife. " Let’s start here and cut downwards.”
If it is a common lumbar disc herniation, Kawei may place the incision 1.2-1.5cm next to the spinous process instead of the midline.
However, the old marshal's protrusion was obvious and the symptoms were very severe. Most of the lamina had to be removed during surgery, so the only choice was a midline incision.
"Give me the diluted adrenal gland extract." Kawei waved to Hills, took a syringe, and injected the liquid inside into the subcutaneous and paravertebral muscles. "Knead it slowly, and then cut it." Opening the skin can reduce a lot of bleeding and give me the scalpel.”
The syringe and blade were interchanged, and the latter directly cut open the skin of the old marshal's lower back and entered the subcutaneous area. The fascia is incised along the midline of the spinous process and interspinous ligament, and then the paravertebral muscles on both sides are peeled off. 【5】
"Periosteum stripper."【6】
The reason why the surgery has been delayed until now is that in addition to Kawi’s need for some practice, the equipment is also an important factor in his waiting.
Intra-abdominal surgeries in general surgery involve delicate organs and can be performed with the most basic needles, threads, forceps, and knives. But orthopedics is different. When the surgical area and method are changed, the instruments also need to be changed. At least the saw used for ordinary amputation cannot be used on the spine.
Therefore, Kawei needs to re-build a set of surgical instruments specifically designed for modern orthopedics.
"We first peel off the paravertebral muscles from the spinous process and lamina subperiosteally. We should peel them off as subperiosteally as possible to reduce damage to the paravertebral muscles and avoid secondary bleeding. The scope of dissection includes lumbar 4 and lumbar 5. The upper and lower half laminae of 5. The range of peeling from the spinous process and the lamina to the inner edge of the facet joint should be expanded to the outer edge of the lamina to avoid damage to the facet process and joint capsule." [7]
Kawei held the stripper in his hand and slowly peeled off the muscles on the bones: "The order needs to be from waist 4, waist 5, and then the inner side of the articular process of waist 4." [8]
The periosteal stripping took some time, but it was this time that allowed Waterman to ask some questions about the surgery. His focus was on the feasibility of surgery because, at this point in time, no one had linked sciatica to Virchow's tumor. 【9】
"Professor Virchow has a biased understanding of bones. This is not a tumor, but a piece of soft tissue called an intervertebral disc that has burst and protruded." [10]
Kawei explained: "And its protrusion just presses on the nerve, so sciatica occurs. By the way, I remember that Dr. La Segue in France has discovered the relationship. If I remember correctly, he should Only if you have published relevant papers." [11]
"Dr. Russegue?" Waterman frowned, "Is there such a thing in his paper?"
Orgi and Maximov stood beside the operating table, shaking their heads: "Don't talk about the paper, I haven't even heard of this person's name."
"Probably a very low-key doctor."
In fact, Kawei is not sure whether it has been published. There are too many papers and they are too complicated. Various medical journals receive hundreds of manuscripts every day. But what he is sure of is that Lasegue is the inventor of the straight leg raising test, and he has been using this test since a long time ago: "It was only through Dr. Lasegue's examination that I clarified the condition of the old marshal."
"Oh, that's it." Waterman also read all the major journals, and he didn't expect that he would miss this important discovery. "I'll go talk to him after the operation."
"Then I have to go and take a look."
"Okay, let's go together."
kindness? ? ?
This time, Kawei couldn't help but asked: "Are you going to Paris together?"
"Why are you going to Paris? He lives in the embassy and is the temporary medical adviser to French Ambassador Edward." Waterman said, "I heard that he will stay in Vienna for three months. He probably came here to relax. By the way, he I sat next to Edward to watch your surgery before, don't you know him?"
Is that person Lassegue?
Kawei was a little confused, but his movements were driven by muscle memory and kept peeling off the periosteum: "Oh, I really don't know him. I didn't expect that person to be Mr. Laseg. I have only heard of his name and special inspection methods. I’ve never seen a real person.”
A far-fetched explanation, but very common in the 19th century. Photography was not popular, it was difficult to record all facial features in portraits, and transportation was so inconvenient. It was not easy to get to know someone and remember someone. The situation Kawei mentioned happened at any time.
"Then let's go together after the operation is over."
"By the way, I will bring you the surgery process and let the French doctor see the Austrian surgery method."
"Um, okay." Kawei had no reason not to go, so he could only agree.
It's a big lie, but it's not that it can't be rounded off. It's just a matter of blaming it on some unknown adoptive father, the doctor. What he is thinking about now is not how to tell the lie, but how to perform the operation well: "Give me wet gauze." [12]
Hills had been watching the operation and was very interested in the periosteum stripping. He handed over the gauze and asked, "What will happen if this layer of periosteum is not stripped off?"
"There will be a lot of bleeding, and the subsequent laminectomy will be difficult to perform." Kawei said, "This is actually the same as the separation of anatomical structures in abdominal surgery. If you don't separate, you can't see clearly. If you can't see clearly, there's nothing you can do. When cutting, it’s easy to make mistakes if you force the cut.”
During the conversation, Kawei had already peeled off the periosteum around the vertebral plate together with the muscles: "Give me the retractor." [13]
The emergence of the retractor has greatly reduced the workload of Orgi and Massimov. Both of them are elderly, and pulling up the hook is very labor-intensive: "This is really a good invention, it frees up both hands. As we get older, After that, it was really useless to do anything.”
Massimov also shook his sore and swollen arms, and had to admit: "Oh, my shoulders are really becoming more and more unable to withstand such torment."
Both of them despised themselves for being old, but their eyes were fixed on the incision opened by the retractor, wanting to see Kawei's next surgical operation immediately.
The retractor not only retracts the skin and subcutaneous tissue, but also pushes the paravertebral muscles apart to completely expose the underlying vertebral lamina. At this point, the surgery begins to get out of the warm-up phase: "The following is the ligamentum flavum between the vertebral bodies. We need to remove the ligamentum flavum and completely enter the vertebral body space."
The four of them stopped talking, and the room instantly became quiet.
They had experienced autopsy and Kawei's training, and knew that the operation had officially entered a difficult and intensive area.
The nerve roots and joint capsule can be seen below the ligamentum flavum. A slightly careless operation will leave irreparable damage to the old marshal's central nervous system.
Kawei compared the cutting area and said: "Let's hurry up and give me the osteotome and rongeur. Before dealing with the ligamentum flavum, we have to break the upper lamina first." [14]
[This chapter with 4000 text + 2000 is considered a big chapter]
(End of chapter)
