Nineteenth Century Medical Guide

Chapter 308 304. Craniotomy

[The idea of ​​​​spiritual diagnosis without imaging is relatively hard-core, you can skip it if you don’t understand or don’t want to read it]

Intracranial hemorrhage caused by traumatic brain injury is very common, and it is also a situation often encountered in modern surgical emergencies.The patient's condition is serious, and the doctor's consultation time is limited. For the accuracy of the results, the patient is often sent directly to the CT room or MRI for imaging examination.

Because even if it takes time to do a physical examination and the nature of the disease can be clarified, it is still the subjective judgment of the doctor, and the objective results of imaging examinations are still needed as the basis for diagnosis.

So it gives ordinary people a feeling that modern medicine can't do anything without equipment.

Just like the positioning of the herniated intervertebral disc for the old Marshal Ludwig, this is an illusion succumbing to accuracy, especially in the modern age when CT is popularized, complicated physical examination has become synonymous with inefficiency and unobjectiveness.

It is true that many physical examinations lack specificity, and the results of the instrument are more intuitive and more accurate. However, even the most common blood counts require manual review to give the final result after the machine judges that there are obvious abnormal values. result.

There is still a long way to go before human science and technology are completely separated from human beings, and medicine may lag behind other disciplines by a few days.

Back in time half an hour ago.

It seems that Carvey just stood by Shebasto's hospital bed and looked at his eyes, took off his shoes and scratched the soles of his feet a few times, as if he had done nothing.

But his mind was racing at high speed trying to make a diagnosis.

After enduring the sour smell and giving Shebasto a Pap test on the soles of his feet, Carvey could actually guess that there was something wrong with the chief of police.The reason why it cannot be determined is that the director did not have a single craniocerebral injury, but also a superimposed alcoholism.

Clinically, it is very difficult to judge acute alcoholism and cerebrovascular accident only by doctor's experience.

In addition to alcoholism, there is also hypoglycemia after heavy alcohol intake.They are all likely to produce vertebral tract damage similar to that in cerebrovascular accidents, that is, positive Bartholin's sign (scratching the soles of the feet). 【1】

However, it is rare for both feet to be positive at the same time in alcoholism, and hypoglycemia after alcohol needs to meet certain conditions [2], so Carvey is still more inclined to subdural hematoma caused by trauma.

After all, the impact of the back of the head on the edge of the table and the contusion on the back of the head are objective, and there are differences in the size of the left and right pupils.

However, with these experiences, the diagnosis is still not clear, and the difference in pupil size is also very subtle, and the risk of craniotomy is huge.Intraoperative hemorrhage, postoperative infection, neurological impairment, postoperative cerebral edema, and postoperative rebleeding may kill Xie Basto.

Unless it is clear that his life is in danger, Kavey will not choose to have a craniotomy.

The first thing he ruled out was hypoglycemia after alcohol.

The crux of the matter is the sweetness of modern and 19th-century alcoholic beverages, where wines of the past required a lot of added sugar.Adding sugar is not because people's taste has changed, but because of limited winemaking technology and grape cultivation technology, which leads to excessive acidity in wine.

Even in France, where the taste is relatively light, the amount of added sugar in wine is 150g/L, while the sugar content in modern wine basically does not exceed 50g/L. 【3】

Half a year has passed since time travel, and Kawei has tasted a lot of wine.Wine merchants are willing to add sugar to wine. Anyway, human beings have an almost instinctive preference for sweetness, and there is no harm in adding more.

This is a conclusion drawn purely from the taste, but Carvey has no research on wine after all, and there is no complete data to support it.So after thinking twice, he still chose to give Shebasto some sugar solution to prevent (combat) possible (already) hypoglycemia. 【4】

Remove hypoglycemia, and the options are alcoholism and cerebral hemorrhage.

Carvey did not have a good way to identify it, and what he could tell was the poor brewing process of the wine merchants. At that time, the understanding of alcohol poisoning was limited to chronic poisoning, not acute poisoning. 【5】

others.
"Stethoscope, do you have a stethoscope here?"

"Have."

"give me one."

The stethoscope of the Main Palace Hospital is also as good as the Municipal General Hospital. It is heavy, troublesome to carry, and the sound quality is not good and there is no sound insulation.

Carvey was familiar enough with cardiopulmonary auscultation, but it had to be confirmed repeatedly before he could tell that the arrhythmia that should have existed did not appear.

Alcohol often affects the beating of the heart, and in severe cases, there may be damage to the heart, which is a relatively specific symptom.If the cerebral hemorrhage wants to reach the same degree, further brain herniation must occur.

But faced with a heart rate close to 100, he still couldn't do this multiple-choice question well.

What really made Carvey decide to have surgery were two things that happened after the soles of the feet were checked.

The first happened when the Pap syndrome was just done, and it was also when the nurse suffered from foot odor and was praying devoutly to God to get rid of this torture as soon as possible.From her point of view, God must exist because she just finished praying and got rid of her smelly feet
Then I accidentally fell into the smell of urine.

The deactivation of the sense of smell made her smell an even weirder smell soon: "This is. It stinks!"

"It seems that our police chief is incontinent." Carvey looked at the pair of trousers on his body that were stained with light yellow liquid. It’s really unreasonable not to wash it.”

Incontinence is a more specific symptom label.

First of all, the smell is normal, there is no ketosis, even if it is diabetes, the sugar supplement just now will not make Xie Basto into ketoacidosis.Combining incontinence with subtle changes in pupil size, Carvey has been able to make judgments.

However, Director Shebasto himself seemed uneasy, and soon delivered a decisive blow-vomiting and convulsions.

Since the sugar water had been given, Carvey immediately ruled out the possibility of hypoglycemic convulsions and attributed them to seizures.The vomiting did not appear jet-like, but simply vomited some contents, which is considered a blessing in misfortune. 【6】

In more than 20 minutes after the Papanicolaou sign ended, Carvey had locked the diagnosis on intracranial hemorrhage.

But the diagnosis is not over here, and it can even be said that it has just begun.Intracranial hemorrhage itself still needs to be identified. The first thing to do is whether the bleeding site is subdural or epidural. 【7】

This is important because subdural and epidural hematomas are managed completely differently.

Fortunately, it is not difficult to distinguish between the two. Basic judgments can be made from the injury method and the nature of the wound alone.

Xie Basto's trauma is a deceleration injury, and there is no skull fracture at the same time. This has been confirmed during the suture, so it is very likely to be a subdural hematoma. 【8】

After clarifying the location of the bleeding, and looking at the pupils in turn, you can see that the amount of bleeding is not small.If it is dragged on, the difference in pupil size between the two sides will further widen, and the light emission will disappear completely.By that time, the hematoma had turned into a herniation.

Carvey sighed, and said to the nurse: "Go to prepare for the operation theater, Mr. Director needs to perform the operation immediately."

The nurse has been so busy taking off her shoes, changing her pants, and helping to hollow out the dirt in her mouth. She thought she could finally calm down, but who knew it would turn out like this: "Are you sure? Are you sure you want to operate now?"

"Of course." Carvey glanced at the wall clock on the wall, "Time is tight, hurry up and get ready."

More than half an hour later, Cedieu, who walked out of the dissection room, learned the whole story from the nurse.He walked into the auditorium of the surgery theater alone and became the only audience here.He even waved to Kawi and Paion in the operating area, showing a calmness beyond ordinary people's comprehension.

It's just that under this layer of composure, there is no such thing as his surgical director's spirit, but his shock and crazy question marks.

Why did Carvey have to have a craniotomy?What kind of surgery is this? Did he come out of a Renaissance painting?
And why do you need surgery at this time?Is he crazy?This is the chief of the police station, how could he just pry the chief's head off casually?What if it breaks?
How many blood vessels are there on the surface of the brain?Just remember a middle meningeal artery, and then?This blood vessel seemed to burst at the touch of a touch, and the bleeding was exaggerated to death.This is not some lame rhetorical technique, it is really about to die! ! !
Even if the prying was done correctly and the blood vessels were not broken, facing the tender brain in front of him, what should I do next?what to do? ! !
As the chief of surgery at the Main Palace Hospital, what should I do?
Stop him and prevent him from undergoing surgery?Can I stop him?I remember Edward said that he is under the control of the Ministry of Foreign Affairs, we can only cooperate
wrong!Am I just watching in silence as he penetrates the skull of the Paris police prefect and grinds his brains to a pulp?

Made, said he was looking for a surgeon to perform on tour, why did he call a lunatic! ! !

"Professor Cedieu, so you are still in the hospital." Carvey took a tool similar to a woodworking clamp from Paion and fixed it on the operating table together, "If I knew you were here, I would have let Peon Ang is looking for you."【9】

It's a complete scene, but Cedieu can't listen to it now: "Well, it doesn't matter, I can just watch from the audience."

Carvey and Peon put Shebasto's head on the pillow together, placed it in the middle of the iron clip, and stuck two thick cotton cloths on both sides to prevent scratches, and then fixed it with nuts: "Professor Cedieu hasn't seen it very much. Craniosurgery."

"I saw someone do it a few years ago."

"What do you think of Professor Cedieu?"

".Huh?" Cedieu was stunned for a while before reacting, but he only responded halfway, maybe not halfway, because he didn't understand what Kavey was saying at all, so he could only smile and say, "It's good ,hehe."

Carvey slightly adjusted the angle of Shebasto's head, and then laughed: "It turns out that the professor is also interested."

"Yes, I am also very interested in craniotomy." Cedieu smiled more naturally, but his mind became more confused: what the hell am I talking about.
"I see." Carvey picked up a razor and asked, "How about the professor come down and help me?"

"No, no, no, I'm just interested, and I don't want to do it myself." Cedieu completely gave up resistance, and answered the question instinctively, "Doctor Carvey, please do it yourself, I'll just be a witness."

"I didn't think about it. It's really wrong if you come down." Carvey scraped Shebasto's hair with a knife, "Think about the earliest craniotomy I saw was done by my father. I was only seven years old, and now ten years have passed in a blink of an eye.”

Kawei's reminiscence of bitterness and sweetness did not arouse Cedieu's sympathy, let alone arouse his nostalgia for the past.

On the contrary, these insignificant words made him more nervous, and his reason was like Shebasto's curly brown hair, which was shaved by the razor in Carvey's hand and fell to the ground in pieces.

Next, Carvey will state the whole process of the operation in a tone similar to that of a teacher.The slightly arrogant tone, the stable and refined operation technique, and the confident aura of putting everything under control reminded Cedieu of his teacher, Dupont Itran, the former king of surgery at the Main Palace Hospital.

The scene of this operation is far less exaggerated than the previous ventriculocentesis in Vienna, but the stimulation to Cedieu may be greater and more profound than that of Massimov.

"First of all, the purpose of the operation must be clarified. The reason why Mr. Director is undergoing surgery is because trauma has caused intracranial hemorrhage." Carvey first pointed out the trauma on Shebasto's left posterior occipital. "This type of trauma itself is only a skin trauma. , but would cause recoil, resulting in a subdural hematoma."

Compared to Cedieu, who was almost autistic, Peon seemed more active: "Why can you be sure that there is a hematoma in the skull?"

"Let's focus on the surgery itself first." Carvey cleaned Shebasto's head briefly, picked up the skull drill, "I'll talk about the rest after the surgery is over.
First of all, it needs to be clear that the purpose of surgery is not to stop bleeding, nor to suture blood vessels, but to let blood out. "Carvey pointed to the skull and said, "The skull protects the brain, but it also gives the brain a great restraint. Internal bleeding will squeeze the space of the brain a little bit, and finally crush the brain like crushing a hard-boiled egg. "

When the purpose of the operation is clarified, and the understanding of intracranial hemorrhage and subdural hematoma is also known, the next problem will arise as the times require.

Where is the bleeding?
Where is the hematoma?

Facing Shebasto's bald head, where should Kavi's drill bit go?

This is not only a question that Peon and Cedieu want to know, but also a question that most modern neurosurgeons cannot solve.

Physical examination can achieve qualitative diagnosis, but cannot achieve precise positioning.Carvey can judge the possible location of the hematoma from the vomiting and epilepsy, but the skull is not the stomach, and a thorough craniotomy needs to remove all the skulls, which is obviously not possible.

"Next, I chose to drill holes to continuously explore the intracranial situation, and search for the possible locations of hematoma in sequence."

(End of this chapter)