Nineteenth Century Medical Guide

Chapter 309 305. Opening, Cleaning, Coagulating Blood
In the eyes of Paion and Cedieu, the so-called investigation is like looking for Xiaoqiang's nest in the ward. It is possible to look anywhere, but you may not be able to find it if you drill all the walls.But for the investigation that Carvey said, at least one must first know where the hematoma is most likely to appear, otherwise there is no way to start.

Borehole exploration itself is not blind, but also has position determination.Even with some lottery components, it still relies more on the accumulation of experience.

At the time when Carvey was a doctor, only large hospitals in the country had CT machines, and if he wanted to locate intracranial hematoma without a CT machine, he relied on drilling.For the deceleration injury caused by the back of the head hitting the object when the back of the head hits the ground or falls, there is a relatively complete detection sequence.

"When the focus is on the back of the brain, that is, the occipital, our exploration sequence is ① the bottom of the contralateral frontal lobe—②the bottom of the ipsilateral frontal lobe—③the pole of the contralateral temporal lobe—④the pole of the ipsilateral temporal lobe. "【1】

Carvey found a chair and sat on the top of Shebasto's head, tapped his forehead with a drill bit, and asked Payne to draw a number circle with a black pen on the four preset positions: "If you don't find these places Hematoma, the last thing to look for is the ipsilateral occiput or posterior fossa.”【2】

The reason why the frontal lobe was first targeted for the posterior occipital injury is because Xie Basto suffered a deceleration injury on the left occipital.This type of injury causes limited damage to the force-bearing position, and is often blocked by the skull, but the corresponding force will be transmitted forward, resulting in a reverse impact.

So the most likely thing is to damage the opposite side, that is, the right frontal lobe.

The frontal lobe damage also coincided with Shebasto's incontinence, vomiting, and slightly dilated right eye pupil.

"The occipital injury is at a high position, so we choose the bottom of the frontal pole, at the intersection of 3 cm above the eyebrow arch and 3 cm next to the midline, and cut the scalp first." Carvey used a scalpel to gently cut the skin for separation, "Remember , Be sure to determine the drilling position first, and then make the incision, and the incision needs to pass through the drilling position."

"gauze."

"tissue forceps"

"Sewing thread." Kawei handed two small retractors and gauze to Pion, "Protect the incision."

"Ok."

Intracranial hemorrhage will gradually form a blood clot, and the skull needs to be cut to completely remove it. Large bone flap removal is also the most common surgical method.

The drilling that Kavi is doing now is just the preparatory work and helps with positioning.Therefore, the position and size of the skin flap and bone flap should be envisaged when the skin is incised, and unnecessary incisions should be avoided as much as possible, which may cause difficulties in postoperative healing.

Carvey's scalpel drew an arc on Xie Basto's right forehead, and turned all the way to the outside through the top of the forehead, about 5cm long, and the cutting direction was aligned with the right temporal pole【3】.Because it is only drilling for exploration, the cutting length is limited. After the hematoma location is found, the incision can be enlarged to make an arc or horseshoe-shaped flap.

After separating the skin and muscles and gently stopping the bleeding with gauze, Peon deftly pulled it apart with a retractor, and stitched up some blood vessels for bleeding, then Kavi officially picked up the drill. 【4】

Carvey first used the drill bit to make a shallow pit, and then turned the hand drill vertically to the skull, and the hand speed gradually changed from slow to fast. 【5】

Although the French drill bit is different from the Austrian one, the difference in feel is not too big. After two trials, Carvey got it right.Based on his many years of work and previous experience in ventriculocentesis, he is basically sure that his drilling will not make mistakes.

But what he didn't notice was that the strange sound produced by the rubbing of the bone metal drill bit, coupled with the weird background of the drill head, was constantly stimulating the nerves of other people in the theater.

Cedieu didn't think it was too scary, but it was far from the treatment picture in his mind: "Doctor Kawei, can this barbaric method really work?"

"Unless my diagnosis is wrong, the hematoma can only be removed by drilling the head." After the drill bit slowly sank into the skull, Carvey's right hand gradually began to exert force, and the shaking speed further increased. "Besides, amputation is quite barbaric."

Soon the first drilling was completed after a light feeling of falling, the bone debris was washed away, and the dura mater inside could be clearly seen through the hole.

At this moment, Carvey was already convinced that his judgment was correct.As long as it is ensured that Xie Basto really has blood in his brain, the "sin" of unauthorized craniotomy will be self-evident.Even if he couldn't understand the operation, Cedieu knew that hemorrhage would affect the brain.

"This layer is the dura mater under the skull, and further down is the brain tissue, and it is also the location of the hematoma." Carvey pointed to the newly opened hole with the smallest forceps, "It is the same as the peritoneum during the ectopic pregnancy in the morning. , Mr. Sebasto's dura is blue."

"It means there is bleeding in the brain!" Paion answered quickly.

"Well, that's right." Carvey said, "It's the same as my judgment, the bleeding is under the dura mater."

"Then what if the bleeding occurs on the dura?" Cedieu's thinking mode is different from that of Peon. He does not focus on answering and answering, but asks after thinking, "I just think that since there is a subdural Bleeding, of course there must be epidural hemorrhage."

(Both epidural and epidural development are called epidurale, and the prefix epi means "above" in medical terms)
"Of course there is."

Cedieu frowned: "There is also an epidural? But the connection between the dura mater and the skull is very tight."

"It's really tight, so epidural bleeding is often the result of a ruptured artery."

Kavey only spoke half of what he said, and Peon just memorized it silently, but Cedieu was able to infer other cases from one instance and grasp the key point: "With the elasticity of the arteries and the protection of the skull, it is necessary to tear the gap between the dura mater and the skull. Bone fragments punctured an artery after a skull fracture?"

"Yes, an epidural hematoma would definitely have a skull fracture."

Carvey gave the answer, and supported this point with bloody "facts": "In front-line military hospitals, wounded soldiers who have been hit by heavy objects on the head are often received. It is a high-speed injury. Usually there is a skull fracture. , a large epidural hematoma appeared. Because it is arterial bleeding, it is easy to cause shock."

"I see."

At this time, the door of the operating theater was knocked open, and the nurse in the ward ran in with several patients and their family members.Together they carried a small blower, and a large jar of leeches, pig blood, and snails: "Dr. Carvey, here's what you asked for."

"Are there any smaller ones?" Carvey shook his head as he looked at the exaggerated volume of the blower.

The nurse was sweating, her hair was loose, and her clothes were stained with yellow, green and green stains.I thought that I would get some praise for doing so much hard work, but I didn't expect that the young man in front of me didn't understand this at all.

She endured it for a full two hours, and finally broke out: "Dear Dr. Carvey, I don't know how you practice medicine in Austria. At least French doctors don't have as much ostentation as you do. The majestic Paris, you let me Where can I find a blacksmith? I'll have to knock on doors and ask them if they have this 'blower' you want!"

"So this is." Carvey was a little confused by what she said.

"I want it from the bakery at the end of the street! They are just about to close, and they have to send it back at four o'clock in the morning tomorrow!" After talking about the blower, she had to complain about the ceramic pot in her hand: "Oh, that's right! And leeches! Leeches!!!"

The nurse became more and more angry: "The leeches in France are famous all over the world, and the quality and quantity are the best. But your requirements are inevitably too high, and you have to starve the leeches for a week. This is not Austria, not Vienna! Paris, France! There are only people in Paris who haven’t been bitten by a leech for a week. Where can there be a leech who has been hungry for a week!”

Kawei was anxious when he heard that, leeches are very important, if they don’t meet the requirements, it may be too late: “Are these all full of blood?”

"Fortunately, when I went to the pharmacy, a batch of new goods had just been unloaded at the door."

The nurse put the leech on the table in the preparation area: "I heard that it was just shipped from Turkey, and I have been hungry for several days. I don't know the exact number, and I don't want to know. Anyway, that's it. If you think it doesn't meet the standard, there is nothing you can do. A leech alone costs a full 20 francs!! Including the jar, it cost 500 francs in one go!"

"Oh, money is no object."

"Is this a question of money???"

The nurse was very angry. For this operation, she endured foot odor, urine odor, and vomit, and had to travel back and forth for nearly an hour.Thanks to her good brains, familiarity with the surroundings, and good luck, otherwise these things would not be prepared at all.

It's really not gentlemanly to ask a young girl in the 19th century to do something like that in the middle of the night.But Carvey didn't know how to express it, so he could only reply embarrassingly: "Thank you."

The little nurse is just a nurse from a hundred years ago, she has no status, and all she can do is complain.

When she saw Cedieu in the auditorium, she calmed down and did not have another attack.

Carvey put his fingers in front of Shebasto's nose, measured his breathing rate, and then began to direct the work outside the operation: "Put the blower next to the operating table, connect the rubber tube and mask, and pour some air into his mouth. Be careful not to leak air from the interface, and use light enough force to avoid blowing his lungs."

The role of the blower is self-evident, it is to make an air infusion device in Paris, where there is no rubber inflatable bag.This is also what Carvey had to do, for fear of brain herniation in the middle of the operation and inhibition of the respiratory center.

Once the breathing center is suppressed, the breathing rhythm will disappear. The blower is a breathing air bag that forces the lungs to work. The only disadvantage is that it is more powerful.

And leeches are naturally prepared for anticoagulation.

In fact, if the sodium citrate hadn't run out, Carvey wouldn't be willing to get hirudin.

Firstly, the effect of hirudin is too strong and long-lasting, and excessive amount can easily cause coagulation disorder; secondly, the extracted liquid is only crude liquid, which cannot be purified, which will affect the dosage control even more.Adding this stuff to a patient's blood would make autologous transfusions, which already have side effects, more unpredictable, like gambling.

But Xie Basto's situation is too critical, and it has indeed reached the point of a last-ditch effort.

Intracranial hematoma is sometimes accompanied by the rupture of small blood vessels. This kind of blood vessel is deformed in the cerebral cortex. After the rupture, the brain is full of blood. It is difficult to see where it is. There is no way to ligate it with sutures. It is quite difficult to stop the bleeding. .

At this time, autologous blood reinfusion is the final guarantee. If there is no such guarantee, Xie Basto may die here.

"Where's the pig's blood?"

"Here, I just got it from the back kitchen of Charles Restaurant!" The nurse didn't bother to complain about how she got the pig's blood, "How do I get it?"

"Stimulate those leeches with pig blood and snails." Kavi watched as Shebasto put on the mask, and his chest slowly rose and fell, and said, "Step lightly. No matter how lightly, just this strength, slowly Slow down and hold on!"

The nurse on the other side seemed to understand Carvey's words: "Are you letting him eat it, or are you not letting him eat it?"

"Pour out the pig's blood clot in the bottle, and then put only one snail in it, and then put all the leeches in it," Carvey explained, "Let them sit in there for half an hour, neither the blood nor the snails are enough to feed them , but can make them salivate."

"saliva?"

"What do you want leech saliva for?"

Carvey looked at the auditorium: "Mr. Cediyo should have heard me talk about sodium citrate this afternoon."

"The anticoagulant you mentioned?"

"Yes, my anticoagulant is used up, so I hope to postpone the operation in the afternoon. After all, rectal cancer." Seeing that he mentioned rectal cancer, the other party's face became ugly, and he immediately changed his mouth. It was found that the leech's saliva also has this effect."

"Their saliva can prevent blood from coagulating?" Cedieu just asked, and the scene of his bloodletting treatment flashed through his mind. "From what you said, it seems to be true."

The nurse is very tired now, but she still did what Carvey wanted: "And then?"

"Wait for half an hour and induce them to vomit," Carvey said. "Put on gloves and wipe their mouths with a small amount of salt."

The nurse looked at him with a very strange look: "Salt? Wouldn't salt kill him?"

"So what I want is a small amount, and I only touch their mouths, and induce them to vomit. In the end, what is left in the bottle is the leech saliva that has been simply extracted." Seeing that he had almost confessed, he picked up the tweezers and gently lifted the dura, Cut a small opening with small scissors, "Is the rubber tube connected to the suction device?"

"It's connected." Another nurse brought the suction device over.

"Give me the tube, and you shake it." Carvey took the rubber tube, and used scissors to make a rounded shape for the mouth of the tube, so as to prevent unnecessary troubles caused by excessive contact with the brain tissue, "Attention! Do not shake too fast , have to take your time."

"Okay, I'll try."

After repeatedly trying the pressure of the suction device with the palm of his hand, Carvey finally decided to proceed to the next step, cutting the dura mater and decompressing Shebasto's brain: "Make a small incision, but it must not be too large. If the incision Too large, coupled with intracranial high pressure, can easily cause brain tissue to bulge outward.”

Everyone didn't quite understand the meaning of this sentence, but when it comes to brain tissue swelling, Cedieu has some experience.

Back then, he had also been on the battlefield and worked as a military doctor, and he had seen the brain tissue swell outward after the head was broken.Listening to Carvey's description now, it seems that Xie Basto's brain is also undergoing this kind of ordeal.

After cutting the blue-purple dura mater, Carvey quickly moved the rubber hose for suction over.

"There is a blood clot." He tried his best to move gently and quickly, and he had to get rid of any distracting thoughts. "When encountering blue-purple dura mater, no matter what the follow-up is, we should cut it in order to let the patient decompress as soon as possible."

After all, the viscous blood with tiny blood clots entered the glass bottle through the rubber tube.

If I had to use a metaphor to describe it, it would be like a young man drinking bubble tea.

Being able to encounter a hematoma at the first puncture point was not only lucky for Kawei, but also for Xie Basto.But just one drilling can only be used for exploration, and it is not enough to change anything. The scope of the hematoma is much larger than what is seen now, and Carvey needs to continue to do other drilling to expand the scope.

He quickly selected the second drilling location: "Next, we choose the pole of the temporal lobe, which is 1.5cm in front of the ear canal."

(End of this chapter)