Nineteenth Century Medical Guide

Chapter 457 453. Plan 2
It has been a long time since Kawi last saw such a big scene since he treated Geiser for YJ trauma in Switzerland. If the scene is bigger, it can even be compared to the laryngeal cancer removal surgery he performed at the end of last year's tour.

Fortunately, the Hospital Dieu withstood the pressure and kept most of the laymen out. The ones who were allowed in were either the rich or the noble, or their journalist "friends" who could not be stopped for some political mission.

The intention is not difficult to understand, using Kavi's exaggerated surgery to cheer up the gloom after the explosion.

Kawi didn't care. He was used to the mixed crowd in Vienna, so he didn't think it was a big deal. But only he knew how much pressure such a high-risk operation brought.

"Everyone, time is tight, so I will skip the opening remarks and the pleasantries."

Kavi asked the nurse to push Fisher in. "I will not report his medical history. The Hospital-Dieu has prepared a medical history report for you, as well as a record of his recent disease progression. It is a booklet and should have been distributed to you. While we prepare for the surgery, let me first introduce the situation of the cerebrospinal fluid leakage."

"Now everyone understands cerebrospinal fluid rhinorrhoea, which is actually just like a leaking pool. Locating the leak is the key to treatment. Only with precise positioning can the surgical approach be determined and damage to brain tissue during surgery be minimized."

Cavey still follows the established modern surgical thinking. Some of the content taught may be deleted or modified due to the anatomical knowledge of the 19th century, but he still skips over "what" and "where" cerebrospinal fluid is and directly explains the problem itself.

It’s like a bunch of newbies listening to a senior electrician talking about how to solve wiring problems. Their levels of understanding are not on the same channel, and even the problem itself is an unknown area for them.

Kavi will definitely not slow down because of these people. As long as someone can understand it, this operation has its meaning.

He quickly showed the results of the explosion simulation:

"In order to minimize the impact on Mr. Fisher's brain, I chose to use a complicated explosion simulation. This morning, I purchased 114 skulls and six bodies, and placed them according to his height and distance from the explosion. I used three explosions to simulate the explosion scene at that time, hoping to find the most likely location of the skull base fracture.

It may be due to the angle of the explosion, or the penetrating wound to his eye, or some other reason I can’t think of, the final data was not one-sided.

其中颅底保持完好的占了40.83%（49），剩余的颅底骨折中，额窦破裂占比46.5%（33）、筛板破裂53.5%（38），蝶窦蝶骨骨折42.3%（30），颞骨骨折21.13%（15）。

The ethmoid plate is most likely to rupture, but considering the presence of multiple fractures, the difference between the frontal, ethmoid, and sphenoid is not that big. If we only look at single fractures, the proportion is only 36.6%. If we look at the four locations, the probability of ethmoid sinus rupture is still the highest, but because the sample size is too small, it is not very meaningful. "

[Simplified lateral view of possible locations of cerebrospinal fluid rhinorrhea]
This is what Kavi called Plan 1, which can avoid the possible side effects of Plan 2 and directly rely on statistics to determine the location of the leak. Unfortunately, the result was not ideal. Not only did I have to work all day, but I also spent 3000 francs and a lot of favors.

Of course, Kawi has long been accustomed to this situation. There is a lot of useless work in medicine, and it is normal to not get any reward.

In fact, plan 1 can still be implemented. After all, the data is there, and the cribriform plate and ethmoid sinus are the most likely locations, so we can just explore them directly. If we find the wrong location, we can expand the scope of the skull incision to make the exploration easier.

However, it is very difficult to implement. Large-scale cranial exploration is very likely to damage brain tissue, and prolonged exploration will greatly increase the chance of cranial infection.

In fact, Fisher already had some signs of brain infection, but it was not as severe as the postoperative infection in the eye socket. But if the scope of the skull incision was really expanded, once severe encephalitis occurred, it would be tantamount to a death sentence.

Since Option 1 cannot accurately determine the location of the leak and the operation is difficult to perform, the serious side effects of Option 2 are acceptable in comparison.

This is also the reason why Kavey gave the surgery rights to Fisher.

If he doesn't have surgery, he will die. If he has either surgery, he will die, or even die faster. The most fatal point is that no matter whether he has surgery or not, he actually has a chance of recovery. After all, cerebrospinal fluid leakage can be blocked by his own brain tissue. It's just that the chance depends entirely on luck.

The road ahead was complicated and confusing, so Kavey could only let Fisher make his own decision: "In the end, he chose Option 2, which is also the option I hoped he would choose. Compared with the almost certain death from postoperative intracranial infection, the side effects during the operation actually give him a chance of survival."

At this time, Fisher took off his shirt and lay on his side on the operating table. Kawi marked the injection point on his lower back. Landreth and Payon helped with preoperative disinfection and laying of towels.

Many people in the audience did not understand why a 100% craniotomy surgery started at the waist.

Of course, they didn't yell or laugh, they just didn't understand, didn't understand Kawi's motives. This misunderstanding was like an infectious disease, sweeping the entire audience during Kawi's hand-washing stage, and a considerable number of the audience secretly questioned the surgical method.

This is actually a good thing. Doubts lead to discussions, and heated discussions lead to more possibilities for surgery. As long as it does not affect his own surgery, it is fine with Cavi.

However, this seemed to touch Landreth's sore spot.

He watched as Kavey drew two schematics for Fisher, and he knew the difficulty of the operation and the innovation of Plan 2. If the surgical theater is a paradise for surgeons, then questioning this operation is blasphemy!

Of course, this is only limited to this operation. After all, as long as you learn it, you will become one of the gods. If there are too many gods, they will not be effective.

"Can you guys be quiet?" Landreth imitated Kavi and slammed the iron basin filled with carbolic acid with a pair of long pliers holding a ball of sterilized gauze. "How old are you? Do you know what teaching surgery is? Did you have this attitude when you took Mr. Dupont Itron's class?"

After mentioning this old man, many people shut up. However, there are always troublemakers. Seeing that Kawi had not yet come on stage and was only halfway through his speech, a few people would always try their best to focus their attention on themselves: "For cerebrospinal fluid rhinorrhoea, why is the surgical area on the waist?"

Landreth handed the things to Albaran, walked up to him and looked him up: "So it's Dr. Mond Kofman from the Grande Hospital. Oh, no, maybe we have to remove the prefix "Grande Hospital", otherwise..." Before he finished speaking, the other party's face turned dark: "I did resign, but I am still a member of the Surgical Association. This time I came to the Divine Palace Hospital to watch the operation. It's normal to have doubts in the operating theater. Haven't you ever doubted Dr. Kavi?"

"Alright, alright." Landreth spread his hands and started talking about the matter at hand. "Although this knowledge is quite biased, I still have to ask you one question. You don't know that cerebrospinal fluid can enter the spinal cord, do you?"

"After all, I have been studying in the anatomy lab for more than ten years. I am not a young man who just graduated from medical school. Of course I know this!"

The man stood up excitedly, rolling up Fisher's medical records in his hand into a small stick and waving it in the air as he spoke. "Besides, Professor Magendie discovered 20 years ago that the middle hole of the fourth ventricle connects the ventricle with the subarachnoid space."

[In 1828, the famous French physiologist Magendie confirmed the connection between the cerebral ventricles and the subarachnoid space, discovered the central hole of the fourth ventricle, and invented the term "cerebrospinal fluid" in 1842. This hole was later named after him, the Cone of Magendie]
"Since we know, why should we have doubts? Although Professor Magendie's discovery of cerebrospinal fluid has almost no clinical application, the word cerebrospinal fluid itself proves this fact, 'brain', 'spinal', 'fluid'."

Mond explained: "The cerebrospinal fluid has pressure, just like the blood has pressure. Rhinorrhoea has already occurred, which means that the pressure of the cerebrospinal fluid is decreasing. If another position is opened, the only cerebrospinal fluid will disappear! I can't imagine how many serious symptoms the patient will have if the cerebrospinal fluid pressure decreases further!"

Although Kavi was washing his hands, he kept listening to their debate.

Mond's theory borrowed from blood pressure, which sounds a bit absurd, but the conclusion is correct. An important symptom of cerebrospinal fluid leakage is a decrease in intracranial pressure. The fact that he could think of this shows that he had a good foundation in anatomy and a certain understanding of cerebrospinal fluid leakage.

But Landreth didn't care about that and didn't follow his lead at all: "Why is the surgery department so stubborn? Opening another position means we can only leave but not come in?"

"Get in? How? What do you use to get in?"

"You don't understand anything, can't you just watch the operation?" Landreth still knew the rules and didn't explain the steps of the operation. "Kavi is not a machine. Which operation don't you explain?"

6◇9◇Book◇Bar

Mond held back his anger because of the gentleman's black coat he was wearing, but he would not accept it until his doubts were answered.

After a brief exchange between the two, Kawi raised his hands, put on gloves, and slowly walked towards the operating table: "Are you done with the marking?"

"Well, according to your request, between L3 and L4." Landreth looked at Mond again and winked at Kawi, "Someone has objections to your surgery, leaving me alone in the dark, and you didn't even say anything to refute it."

"It's good to have debates."

Kavi had no intention of conflicting with Mond. On the contrary, Professor Magandi mentioned by the other party was an important introduction to Plan 2: "In fact, Plan 2 I am talking about is the method that Professor Magandi used to study the structure and channels of the ventricles.

Oh, and Professor Huber von Luschka from Heidelberg University also used this method. But they used it on corpses, and I used it on living people, so the difficulty is also different. "

At this time, Peon, who had already completed the disinfection, left the operating table and handed Kavi a metal syringe.

The people sitting in the front row leaned forward one after another. Some of them with good eyesight noticed that the glass piece in the center of the syringe that displayed the scale was blue. "Is it a dye?!"

"Yes, that's right, it's a dye." Kawi explained, "If you want to find a tiny gap in the human body, you have to rely on methylene blue. In quite a few surgical operations, methylene blue can play a decisive role, and the same is true for rhinorrhoea repair. It can leave a blue mark on the bright red surgical wound, marking the specific location of the leak. However.
As I just said, Option 2 has serious side effects. Nerve tissue is different from other tissues in the body. It has a very strong affinity with methylene blue, which can cause nerve cell degeneration or even necrosis. This is clinically manifested as spinal cord radiculopathy, amnesia, epilepsy, and in severe cases, it can cause shock and mild paralysis, and finally cause whole body paralysis. "

What makes Kavey's surgery so popular, in addition to his counterintuitive techniques, is the large number of unknown details.

The reaction caused by methylene blue entering the subarachnoid space belongs to the category of modern anesthesia. It only exists in the minds of some experienced and senior anesthesiologists. It is a niche knowledge accumulated through a large amount of clinical practice and literature reports of accidental entry into the subarachnoid space.

If it is changed to modern, the contrast agent used is gadopentetate dimeglumine, which can be seen very clearly under MRI. Or other radioactive contrast agents can be used for tracing, such as iodine 131. Even if there is no imaging examination, indigo carmine can be used, also known as indigo red or sodium indigo disulfonate. Like methylene blue, it is a mucosal stain, but it is safer than methylene blue in terms of its effect on nerve tissue.

Unfortunately, even though he knew all this clearly, this was the only thing Kavi had, and it was already the safest mucosal dye at this stage.

The last time Kavi performed a lumbar puncture was at Fort Olmütz, to treat a soldier from the 11th Rifle Regiment for a penetrating cranial firearm wound.

Now that this was a rare opportunity, he briefly described Ronane's condition: "It's really amazing that Dr. Mond thought of lowering intracranial pressure. This is a conservative approach to dealing with intracranial hypertension after craniocerebral injury."

At the same time, he never stopped moving, allowing Peon to brake for Fisher and expose the penetration point.

Because there was no local anesthetic, Kavi performed the puncture directly. However, unlike the Prussian-Austrian War, he chose the side entry method to prevent accidents and delays.

"We apply pressure 1.5 cm away from the midpoint of the spinous process gap, and after the puncture needle and the skin form a 75-degree angle, we aim at the middle hole of the spinous process and pierce it."

Kavey asked the intern to take out the spinal model and explained: "This insertion method can effectively avoid the supraspinous and interspinous ligaments, and is more effective for the elderly or patients with ligament injuries. The patient is a carriage driver. He has been working for more than ten years, and back injuries are inevitable. For safety reasons, I chose a side entry."

As soon as he finished speaking, the needle broke through the yellow ligament and dura mater with a muffled groan from Fisher and successfully entered the subarachnoid space.

After some cerebrospinal fluid was released, Cavi slowly pushed in a whole tube of 5 ml of diluted methylene blue solution.