Nineteenth Century Medical Guide

Chapter 460 456. Magical Little Thing
Not to mention the backward technology of the 19th century, even today doctors have no conventional means to predict the occurrence of allergies and drug irritation in advance, and all they have are probabilities composed of numbers. But for patients, the probability is only 0 and 100%, and only when it really happens and meets the criteria of allergy and irritation can it be qualitatively diagnosed.

The side effects of methylene blue are real, and Fisher's condition is consistent with the stimulation of the central nervous system by methylene blue. Because the only drug that can counteract it is adrenaline, if you want to cure it, you need to use sugar and saline to wash the cerebrospinal fluid, and wash away the residual methylene blue to relieve the symptoms.

Of course, in order to further reduce irritation, temperature maintenance is also necessary.

"Why are they taking so long?" Kavi had already pushed and pumped several times, and the cerebrospinal fluid that was washed out gradually turned back to its original color. "Also, I wanted four bottles of saline solution, why did they only bring two bottles?"

Having worked with Kavey on several surgeries and done so many surgical simulations, the nurse knew his temper. If she was slow or slow to react, he would definitely scold her. Moreover, she had knocked over the important warm saline solution: "Originally, we took six bottles, and four of them were broken on the way."

"Broken?"

Kavi looked back at the nurse and found that the other nurse was not there: "How did it break? Did you not hold it properly? Or did you fall?"

"I was bumped into." Holmes repeated what happened just now. "The main responsibility lies with me. I was anxious and pushed the man. I didn't expect that he couldn't stand firmly, and then..."

"never mind."

Accidents often accompany surgery, just like this operation. From the preoperative preparation to the present, there have been several accidents, which cannot be dealt with by human power. In addition, there were no modern infusion bags in the 19th century, and drugs and liquids were completely stored in various glass bottles.

Today, I just broke a bottle of saline, which is not a big problem. At most, I can wait for the boiler room to boil and then add another bottle. If other drugs are broken in the future, such as prepared oxytocin or a glass syringe with adrenaline, and there is a problem with drug reserves, it will be really troublesome.

It seems that I have to look for the rubber factory again to see if they can make matching anti-fall pads.

Kavi silently noted this, pulled out the syringe, watched the clear cerebrospinal fluid flow out of the needle, and asked Landreth to remove the four sutures outside Fisher's nose. The ends of the sutures were marked with marks, corresponding to four cotton pieces in different positions.

While checking the cotton smear numbers and staining, he announced the answer: "Cotton smear No. 1 is located in the middle nasal meatus, suggesting the frontal sinus, because the opening of the frontal sinus is here. Cotton smear No. 2 is located in the front of the nose, indicating that the fistula is in the ethmoid plate.

The ③ cotton piece is at the junction of the posterior part of the nose and the sphenoethmoid recess. This is a relatively coherent anatomical structure and is difficult to distinguish by blind operation. The ethmoid sinus and sphenoid sinus can be indicated respectively before and after staining. The ④ cotton piece is attached to the posterior end of the inferior nasal meatus, where cerebrospinal fluid from the Eustachian tube can be received.

At this point, all four cotton pads have been taken out and placed on a metal tray. The interns will take them to the auditorium and display them layer by layer for everyone to see.

Insufficient time did affect the coloring. Judging from the current results alone, No. ② and No. ④ have no coloring at all, No. ① has more coloring, and No. ③ has some coloring in the front. It can be basically determined that the leakage location is in the cribriform plate and ethmoid sinus.

The reason why the coloration range is larger than expected is probably related to the frequent turning of Fisher's body position. However, the approximate location of the leak has been determined, and the operation can finally begin.

"Everyone, Mr. Fisher was strongly stimulated by the methylene blue just now. His central nervous system function is disordered, and his blood pressure and heart rate are unstable."

Cavi asked Landreth to do the final preparations and change Fisher's position again: "I used adrenaline extract to maintain his blood pressure. The result was good. At least we managed to complete the positioning and know the approximate position. But as far as the operation itself is concerned, the result may not be good, because methylene blue may not be usable anymore."

This sentence seems to be fine, but it always seems strange when you look into it carefully.

The cotton pieces are very close to each other, so there will definitely be errors in the coloring and positioning, but the whole process is over. Now that the results are available, and knowing that the leak is located in the cribriform plate and ethmoid sinus, what does it matter whether methylene blue can be used or not?

Little did people know that the reason why Cavi needed so much saline was not just to flush out the cerebrospinal fluid to relieve shock, but also for the subsequent craniotomy surgery where methylene blue could no longer be used.

Perhaps because Kavi did not ask questions, or perhaps in order not to interrupt the operation, or perhaps because the discussion just now had almost exhausted their passion, the doctors in the audience did not object to this statement. Last year, the police chief's craniotomy was quite mysterious, and some even said that the operation that did not appear in the tour catalog was the main reason why Sediyo decided to go to Vienna.

Now the preoperative preparation time has exceeded half an hour, and the operation is about to officially begin. They have been driven crazy, and all they can think about are the possible steps of the operation.

Even someone like Mond suppressed his impulse, put away his growing curiosity, and sat quietly in his chair, staring at Kavi.

"For the craniotomy of cerebrospinal fluid leakage in the ethmoid plate and ethmoid sinus, I choose the frontal bone approach."

The operating table was changed to a head-high-feet-low position, but a cushion was placed on the back of Fisher's neck to lift his chin and expose his forehead to the back. Kavey gave his position to Landreth and Payon, who completed the preoperative disinfection. "If the leak is located near the sella turcica or the middle cranial fossa of the Eustachian tube, the head can be tilted to one side."

At this point, he turned Fisher's head 45 degrees before disinfection. Then he simply drew a rough area on Fisher's forehead with his fingers: "Cut the bone flap at this position."

After everyone had memorized the approach, he turned his head back and said, "For the lateral approach, we first find the hairline. If there is no hairline or the actual position is too far from the eyebrow arch, we can choose a distance of about 5 cm above the eyebrow and make a coronal flap skin incision."

During this time before the operation, Kavey changed into a mask and gloves, washed his hands again, put on a clean leather skirt, and sincerely warned everyone:

"I know you are all very interested in opening the patient's skull, but before the operation officially begins, I still need to emphasize that craniotomy is very, very dangerous, and the prognosis is very poor. It is the last resort. Even if you have learned it, don't try it lightly. As I said before during the tour, the operation is to keep the patient alive. If the chance of survival is slim, it is better to trust the patient's own body."

Fisher was already bald by then, and the incision sites were marked by Landreth, including the skull drilling points. Payon was responsible for disinfecting Kawi's craniotomy instruments, including the hand-cranked drill, wire saw, wire saw guide, retractor, bone rongeurs, etc. On the other side, Holmes took out a cloth bag from the surgical kit that no one had ever seen before, and poured all the wire clamps inside into the carbolic acid disinfectant.

The rustling sound instantly attracted many people's attention. Considering the limited operation time, the steps might not be explained enough, so Kavi did not waste the pre-operative sales promotion time: "If you have rescued patients with craniocerebral trauma, or scalp degloving or contusion, you should have a deep understanding of the rich blood vessels in the scalp.

If a simple incision is made to stop bleeding before the craniotomy, it is fine for a small incision, which only takes half an hour. If it is a large incision like today, it is very troublesome, and the patient may wake up before the scalp bleeding is halfway stopped. When I was the director of the frontline hospital during the Prussian-Austrian War, I often encountered such wounded people. You can only choose between time and stopping bleeding, which is very helpless and painful. "

At this point, Kavi's tone became very heavy, and his speech speed gradually slowed down, trying to match the disinfection time, as if he was completely immersed in that painful memory. After a long time, he "recovered" and talked about the confrontation method he thought of in the later stages of the war:

"In dealing with massive scalp bleeding, I slowly thought about it and found a simple solution. When I performed the craniotomy on Director Shebasto, I completely gave up suturing the blood vessels and chose to wrap the cut edge with wet gauze and use hemostatic forceps for simple hemostasis.

This method is easy to operate and does not cause much damage to the incision, but its disadvantage is that it cannot guarantee the quality of hemostasis, and there are still many bleeding points between the clamps. Moreover, the hemostatic forceps hanging on the scalp also greatly affects the operation, and the growth of the scalp at the compression site after the operation is not satisfactory.

In fact, compared with scalp sutures, it is very convenient, and it only takes a few minutes to complete a large incision. But I am still not satisfied. I have been thinking about simple hemostasis methods that can not only reduce a lot of hemostasis time, but also have a good hemostasis effect. "

As the disinfection was coming to an end, Kawi's introduction set the mood. There was another rustling sound, and Holmes used a metal sieve to fish out more than twenty wire clips from the carbolic acid disinfectant and dumped them all into the metal curved tray. He was like a French fry chef who had worked in a fast food restaurant for several years, dipping and scooping with extraordinary skill.

"This is a wire hemostatic clamp that I designed and made myself." Kawi used a hemostatic forceps to clamp one out of the curved plate and showed it to everyone. "It is now in a clamped state. You need to use a special flat-mouth pliers to insert it from bottom to top into the U-shaped hole in the middle, loosen the screw button at the bottom of the hemostatic forceps, and open the hemostatic clamp from the front end."

This is actually a simplified version of the modern neurosurgery scalp clamp. The modern one is made of plastic material and curled into a tube shape. Simply loosen the clamp and it will bite the scalp incision by itself to stop the bleeding.

There was certainly no such plastic in the 19th century, so steel wire had to be used instead.

6◇9◇Book◇Bar

Historically, the introduction of scalp clamps in China was quite bumpy. It was not until the 20s that Professor Luo Shiqi of the Department of Neurosurgery at Tiantan Hospital brought back samples from the United States, and then developed domestic scalp clamps and special scalp clamps, and popularized them nationwide. Before that, domestic neurosurgeons used wet gauze hemostatic forceps and Kawi's homemade wire clamps.

Kawi's simple demonstration was like a slow fire, heating up the audience that had just quieted down. Many doctors were obviously interested, and soon they became like small bubbles coming out of the bottom of the stove, asking about the price: "How much, Doctor Kawi? I want to buy 10 for backup."

"I want 10 of them, too! And a pair of special flat-nosed pliers!"

"I want 20 of them! And a pair of flat-nosed pliers too."

Seeing that some people were asking for the price, in order to get the first batch of hemostatic clips smoothly, the bubbles gradually increased. In the end, I simply stopped asking the price and gave a direct quote: "Steel wire products, 10 francs each should be enough."

"This is for surgery only. It's not something that an ordinary blacksmith would just hammer out. It shows the surgeon's skills and precision of operation. It costs at least 20 francs each!!! Flat-nosed pliers also cost at least 100 francs!"

"I'll give you 30 francs for 50!"

"50 francs!!!"

The price has been rising, raising the price of a wire clamp that costs less than 20 sous by 250 times. But the shape of the clamp is very simple, and the only thing that needs to be considered is the force of clamping. What kind of force can ensure hemostasis while not damaging the scalp and allowing the incision to heal normally after surgery? This requires a lot of experimental data to judge, not only animal experiments, but also human experiments.

In the eyes of outsiders, Kavi seemed to have benefited from the Austro-Prussian War, with too many wounded with craniocerebral trauma for him to use and study. But in fact, in the Olmütz Fortress, the environmental conditions were harsh and there were not enough people, so he did not want to perform craniotomy at all.

To this day, even at this moment, there is a question mark as to whether performing a craniotomy on Fisher was really the best option. It was a complete gamble.

But it is undeniable that French doctors, or other European doctors except the British, have too many concerns about craniotomy. Heavy bleeding, excessive skull cutting, skull bone flap dislocation, brain tissue damage, etc. are all difficulties they find difficult to solve. In addition, the technology has not yet been truly mastered, and various accidents during the operation may push the patient into the abyss.

The sudden appearance of wire clips can indeed alleviate a large part of the preoperative anxiety, at least the bleeding can be solved. But the current situation of sky-high prices is not what Kawi wants, and the skyrocketing equipment prices are not conducive to the promotion of surgical operations.

He threw the pliers and clamps in his hands back into the carbolic acid pool, looked at the mobile carbolic acid disinfection pool he designed, and said, "Please be quiet, don't get too excited, this is Paris, and it's just an ordinary wire clamp.

Today is their first appearance, and everything still needs to be observed during the operation to determine the effect. If everything goes well, the price will be announced next month. Of course, only one instrument factory in Vienna in Europe produces this kind of wire clamp, because the pressure during clamping must be considered. Too large or too small will affect the hemostasis effect and postoperative healing. Please identify the genuine product and make reservations actively. "

After introducing the clip, Kavi asked everyone to be quiet, and then instructed Landreth to inject adrenaline into the skin around the incision, while not forgetting to introduce the shortcomings of the scalp clip: "The scalp clip is ultimately just a device, a dead object, and it cannot freely change the pressure of the skin flap to perfectly match the exquisite human body structure.

For example, Mr. Fisher's craniotomy approach was on the forehead, where the skin is thinner than other parts of the scalp, but the amount of bleeding after the incision was not small at all. Using a large number of scalp clips would have the risk of incision necrosis. In order to assist the hemostatic ability of a small number of scalp clips, I chose to add three subcutaneous epinephrine injections for hemostasis, which can effectively relieve scalp bleeding during the operation. "

What followed was another theoretical sermon that lingered on the fringes of modern medicine, mainly introducing the effect of adrenaline in constricting blood vessels, and at the same time linking it to the previous effect of raising blood pressure.

When everything was ready, Kavi finally picked up the scalpel.

(End of this chapter)