Nineteenth Century Medical Guide

The question caught Carvey a little off guard, but he always claimed that his adoptive father was dead and never revealed his name, so it was not too much trouble, and it was over with a few words.

"Dead? How did you die?"

"I accidentally scratched my finger during the autopsy, and then the wound became infected." Carvey made a nonsense account of the most common cause of death for surgeons, "That's why I've been calling for gloves to be worn during surgery. This approach protects both patients and doctors."

Massimov seemed to be even more sad than Carvey: "How could such a skilled surgical master just fall like this?"

"He is just a surgeon in a small place. He has stayed in his own clinic all his life. Even if he has a bright idea from time to time, he is not famous." Carvey drilled hard into Mrs. Santini's skull and shook his head helplessly. "At the beginning, I wanted to inherit the clinic, but unfortunately passed away, so I sold the clinic and came to Vienna."

"It's a good choice. It's a pity to live in the country and not publish a biography." Massimov sighed after hearing this: "Well, if possible, I really hope to have a good chat with him."

"Teacher, let's focus on the operation first." Carvey pulled out the bone drill in his hand and wiped off the surrounding bone meal. "Mrs. Santini's skull has been drilled open by me."

This should be the first neurosurgery performed by Massimov and the two surrounding surgeons. The operating table is the same as before, but the position has changed a lot.Because the brain is not like the abdominal cavity, it cannot withstand the slightest infection, so besides Kawi and Massimov, only one second assistant who passes the equipment is allowed to stand around the head. 【1】

The skull drill was taken away, and Cavet left a layer of dura mater, which did not continue down. 【2】

Just like marching and fighting, surgery must be carried out before the soldiers and horses move food and grass.The conditions in the operating room are poor, the assistants are not strong, and the anti-infection ability is also poor. In order to minimize the exposure time of brain tissue, he put aside the puncture for the time being, and first completed the follow-up shunt access, that is, the implanted tube connecting the abdominal cavity. 【3】

"Give me the scalpel."

Carvey used a knife to make a shallow incision below the puncture point, only reaching the fat layer. After hemostasis, clamp the front end of the rubber tube with tissue forceps and forcefully probe forward, then open the forceps to expand a certain area, and then clamp the rubber tube to probe forward , and then expand.

An obvious tunnel appeared under the skin under this blunt separation, but the length of the tunnel was related to the length of the forceps, and it reached the limit just beyond the back of the brain, and the exit was set at the neck.

After all, it was a conclusion drawn from decades of clinical practice, and it was difficult for Massimov to see the significance of this operation in the first place.

Carvey explained: "This is for the sake of Mrs. Santini's daily life. It is necessary to bury the hose under the skin as much as possible."

The sterilized hose protruded out of the neck outlet, exposed a small part, and then entered the subcutaneous area again above the collarbone.The same routine and the same distance, the second exit was set on the chest by Kawei.Immediately after that is the third section, protruding from the chest to the upper abdomen, and the work of buried tube in the middle comes to an end.

Finally, as long as the puncture of the upper ventricle is completed and the rubber tube is connected, a new incision can be made in the abdomen to officially enter the abdominal cavity. …

This kind of tunnel-digging work seems to be easy, but in fact there are many details to consider.

"The subcutaneous depth must be well grasped. If you are going to do the same operation in the future, please be sure to practice more on the corpse." Carvey put down the tissue forceps and switched to a scalpel. "If the separation is too deep, it will cause bleeding and infection. The nutrient supply is destroyed, and the skin is easily necrotic. The best depth is the fat layer under the skin, and the movements should be gentle.”

Looking at tunneling and hoses along the way, not to mention the second assistant who handed over surgical instruments, even Massimov admired Kavey's basic skills.

The vp shunt operation is to put two holes in the body and connect them with a tube. It sounds very simple, but it is full of details when it comes to actual operation.Now it's just general preparations, and Massimov doesn't have much confidence anymore.

But Carvey's operation further stimulated his desire to learn new technologies: "Do I have to do a ventriculocentesis next?"

"Correct."

If it was in modern times, what the equipment nurse handed over at this time should be a ventriculopuncture needle with a metal guide core【4】.But now the conditions are limited, this kind of thin hollow metal pipe is difficult to manufacture, and it is impossible to have ready-made ones. When you temporarily open the surgical instrument box of St. Mary's Hospital, you can see thicker suction heads.

The suction head inserted into the abdominal cavity is too thick and too long, and the ordinary needle is too thin and too short.

The Municipal General Hospital has silver tubes of similar thickness, which Carvey asked Laszlo to make for catheterization of patients.However, this kind of pipeline only has two openings at the front and back, which is still too simple for the shunting and drainage of cerebrospinal fluid with high protein content, which will lead to poor drainage or even obstruction.

Faced with this difficulty, Carvey could only find another way before the operation: "Where are the quills you collected?"

"It's all soaked in carbolic acid."

"The length is about 10cm, and the diameter is 3mm." This is the puncture substitute that Carvey asked to prepare before. "It doesn't matter if it fluctuates up and down, the key is to clean the surrounding feathers."

"There are a total of 55 pens in the whole hospital. We picked out 3 pens. In order to remove the feathers, we also cut off a layer of the tube wall."

"Is it slippery?"

"Very smooth."

The second assistant who delivered the instrument sent three "piercing tubes", the length and diameter of which met Carvey's requirements.Although the material is not as strong as metal, Mrs. Santini did not use it for a long time compared to other patients who needed shunts. 【5】

"This one is too thin at the front to be usable; this one has too many cracks in the middle to be usable; this... this one is not bad, but it needs to be worked on."

Carvey carefully poked a few small holes in the tube wall with a thin needle, and quickly made a crude version of the 19th century ventriculocentesis needle.Under the premise of ensuring that the outer wall is basically smooth, Carvey holds the pen tube in his hand and prepares to insert it directly into the ventricle from the drill hole. 【6】

This is the key to determine the success of the operation. It is necessary to consider the depth, angle and strength of the puncture. Any problem can range from coma to death on the operating table. How deep is the needle?"【7】

While explaining, Carvey began to push the puncture needle in with force. …

In the entire operating theater, no one spoke, and the two assistants did not perform any other operations. All attention was focused on Mrs. Santini's head.

1cm3cm5cm【8】

The distance from the scalp to the ventricle is not long. In this short distance of 5cm, the surgeon must endure tremendous psychological pressure.Especially when the cerebrospinal fluid still does not appear after the puncture needle penetrates 5cm, the surgeon who puts aside distracting thoughts needs to consider many factors, fighting wits with the patient's brain structure, himself, and even the air.

For novices in neurosurgery, the whole process from the time the needle enters the brain until it penetrates 5cm into the scalp without seeing the cerebrospinal fluid is very exhausting.The degree of disgust increases with the depth, and finally forces them to make a choice.

At this time, there are generally two possibilities.

One possibility is that the puncture depth is not enough, then you need to continue to move forward, maybe you can enter the ventricle by going 1-2mm forward.But if the direction is really wrong, no matter how far you go, you will damage other brain tissues.

The deeper you go, the more damage you get.

It may be from the ventricles, which can cause intracerebral hemorrhage [9].

It may be the diencephalon, which causes sensory disturbances and abnormal emotions; it may also be the brainstem, which affects spontaneous breathing and heart rate regulation. 【10】

If the doctor "coaxes" a little, he may judge that there is no cerebrospinal fluid as a problem with his puncture angle.At this time, you must not change the puncture direction halfway, you can only exit the puncture needle according to the original way and choose a suitable angle for puncture again.

But re-piercing does not mean that the situation has improved, and the problem of puncture angle still exists.If cerebrospinal fluid appears at the mouth of the tube after entering 5cm, then everyone in the operating room will be happy, but what if there is still no cerebrospinal fluid?

At this time, should we continue to deepen, or start again after quitting?
If you choose to continue in-depth, it means that there is a problem with the judgment just now. Is the angle correct this time, or is the angle you chose to quit just now correct?

If you choose to withdraw again, even if the re-puncture is successful, a total of three punctures have caused considerable brain damage, and the patient may have lost a considerable amount of neurological function.For doctors, it was a total failure.

This kind of immediate operation failure can easily create a psychological shadow on the chief surgeon, which will further affect other subsequent operations.

And this is based on the success of the operation, what if it fails even the third time?
Of course, these are all problems that novices who are just starting to do puncture surgery need to worry about.For a veteran like Carvey, even if his hands are unfamiliar, he will have no problem judging the angle of the puncture.

After entering about 5cm, Carvey did not hesitate, and confidently continued to explore a distance of 3-4mm.Suddenly, his fingertips felt an extremely slight vibration, and then a clear liquid with a lot of blood streaked out from the outer nozzle.

"The front end of the needle has entered the ventricle, and it needs to go deeper."

Massimov and his students looked at the sprayed cerebrospinal fluid, and breathed a sigh of relief: "Do you want to go deeper?"

As soon as the words fell, he inserted the entire pen barrel into Mrs. Santini's brain, only a short part was exposed, "Give me the infusion valve." …

This valve can control the flow rate of cerebrospinal fluid drainage outside the body. Although it is much worse than the multifunctional shunt valve used in modern medicine, it is better than nothing. 【11】

The rubber tubes near the valve connect the puncture needle with the lowered rubber tubes, and what Carvey can use in his hand is common surgical tape for sealing.The connection was directly sealed under the skin, and the cut skin was re-sewn with needles and threads, and the side of the brain was finally over. 【12】

"Is that almost enough?"

"Connect the valve, connect the drainage tube below, we will make a hole in the stomach, and put the other end into the abdominal cavity." Carvey let go of some bloody cerebrospinal fluid, and let Mrs. Santini's head drop. Pressed, then closed the valve according to experience, and began to deal with the abdominal incision, "Come on, give me the scalpel."

Now there is no minimally invasive technique and no qualified puncture needle. He can only make a slightly larger incision in the abdomen. He still follows the steps of abdominal surgery to separate the muscles and peritoneum layer by layer, and put the other end of the tube into the omentum. .

The reason why cerebrospinal fluid can be drained into the abdominal cavity is due to the strong absorption capacity of the greater omentum, which can reabsorb cerebrospinal fluid into the circulation and form a new closed loop while isolating external invasion.

This is the theoretical core of the success of this type of operation. For this reason, in addition to abdominal drainage, ventriculocentesis can also perform atrial drainage through the jugular vein. 【13】

"Therefore, everything must be completely closed. Not only the opening of the skull must be completely closed, but also the opening of the lower abdominal cavity, as well as the part of the subcutaneous tube in the middle." Carvey still has some regrets about the operation, "If all the rubber tubes in the middle are closed It would be great if it could be buried under the skin, now we can only hope that there will be no infection.”

"Dr. Carvey, you have done a very good job!"

Massimov is an eye-opener, which is more exciting than the modified mastectomy, and every step is so fresh and exciting: "If this kind of operation can really reduce the pressure on the brain and headache for a long time, then in Does it apply to children with cerebrospinal fluid (hydrocephalus)?"

"After all, children have to grow their bodies." Carvey hit the point. "Height growth is a very troublesome problem."

"If it is really successful, it is actually acceptable to change the hose frequently. After all, these children will die soon, and there is no other way."

"That's the problem of infection. This kind of surgery is very easy to get infected, so you must be careful in the operation." Ka maintained a pessimistic attitude, but still praised him with a smile, "Mr. Massimov has a good idea, you can try it."

The operation was completed under Carvey's operation, followed by some routine postoperative observations. At the same time, it was necessary to repeatedly adjust the flow rate of the cerebrospinal fluid after Mrs. Santini woke up.

As for how to deal with the incision and change dressings after surgery, or how to take methylene blue to fight infection, you don't need to do it yourself.What he and Massimov had to do was to inform Ed Nelson, who had been waiting outside the handwriting theater for a long time, to postpone tomorrow's electrotherapy schedule.

But at this time, there were not only Ed Nelson and Jenny outside the theater, but also Mr. Santini and another man in a black coat.

The man was pacing back and forth with a cigarette in his mouth, his expression was more nervous than anyone else: "Why hasn't he come out yet?"

"It stands to reason that it should be soon." Ed Nelson was still reminiscing about the storm with Jenny just now, and he became less and less optimistic about the results of Carvey's operation. "If the sheriff doesn't mind, I can do it for you. After all, Carvey The doctor's operation is very difficult, and accidents are the least surprising."

"I know you have excellent medical skills, but" Witt said in a dilemma, "but that guy only recognizes him, and it's useless for other doctors to go."