Nineteenth Century Medical Guide

Chapter 461 457. Noble Materials from the Red Sea

Landreth's career can be roughly divided into three stages.

The first stage is the study period, which lasts two years from college admission to doctoral graduation.

At that time, he was considered the most talented student of Dupont Itron. He became his teacher's assistant before graduation and participated in a large number of operations. But he had very strange ideas and always opposed the old man who was about to retire. He thought his surgical procedures were too rigid and the postoperative results were not very good.

His classic remarks include but are not limited to "Teacher is too conservative, surgery needs to break free from its shackles and innovate vigorously", "Teacher is too radical, the importance of surgery is not in cutting, but in repairing and supplementing", "Surgery is an inseparable part of medicine, but it should not show its importance everywhere", "Many of Teacher Dupont Itron's surgeries are unnecessary", "Teacher should not perform surgery for the sake of surgery".
In January 1835, Landreth was expelled from the Hôtel-Dieu by Dupont-Itran.

In March 1835, Dupont-Itran suffered from a splitting headache and suspected a stroke, so he turned down all his duties and went home to recuperate. In September 3, the last recognized surgical emperor in Paris passed away due to severe pneumonia.

DuPont-Itron's death ushered in the second and most uneventful phase of Landreth's surgical career.

The teacher's network of contacts was all over France. Even after his death, Landreth was still unable to get rid of his teacher's control for a long time. No big hospital was willing to accept this troublemaker. He worked in many small hospitals in Paris. In the 40s, when Paris was not peaceful, he went to live in the countryside for a while.

Rural surgery was almost a blank sheet of paper. In order to make a living, Landreth did many miscellaneous jobs, including butcher, lumberjack, shoemaker, miner, telegraph translator, and librarian. During this time, he became fascinated with oriental culture, especially the complex and changeable oriental writing that contained some special rules.

Of course, Landreth's main job was still a surgeon, and he performed surgery on many people, but not as frequently as at the Hôtel-Dieu.

It was not until the outbreak of the Crimean War that his third stage began.

He responded to the call of Emperor Nazianzu III and returned to Paris without hesitation to join the army in the Crimean War.

At that time, anesthesia had already begun to become popular in continental Europe, but surgery was far from being as sophisticated as it should be. The huge destructive power of firearms often caused open fractures, which, if left untreated, would lead to the classic three-step process of "bleeding + infection + death".

After hundreds of years, horse-drawn carriages became trains, human and animal power became mechanical power, simple pain relief became anesthesia, but amputation is still amputation and is still the first choice of military surgery.

Surgeons cannot treat complex wounds caused by bullets and fragments without sterilization. The more complex the wounds, the worse the prognosis. In a circle, they still choose the method of hundreds of years ago, relying on amputation to change complex wounds into simple wounds that are easy to treat, including Landreth.

Although there are still countless postoperative infections, the mortality rate is greatly reduced.

The three years of war honed Landreth's surgical skills to perfection, and no one could deny his surgical skills. In the winter of 1856, Landreth was taken back to the Hôtel-Dieu by Sedijo to serve as his deputy. Unfortunately, within a few years, he once again became obscure and resigned from the hospital.

At that time, Le Figaro's evaluation of him was: He was like a steam engine that was running at high speed and suddenly had its coal taken away. It had slid on the track of the Hôtel-Dieu for four years and finally stopped. Now it was no different from a cold dead object.

After leaving the Hospital Main, he returned to his original village and his original life. Landreth was already in his forties at this time, and thought that his life would end like this, and it would be nice to have a plain and simple ending.

Unexpectedly, seven years later, Sediyo knocked on his door again.

Landreth had never performed a craniotomy before, and the only experience he had was from when teacher DuPont Itron taught him surgeries.

At that time, some patients died on the operating table, and some died in the post-operative ward. His so-called surgical innovation and DuPont Itron's so-called glory of surgical medicine were casually thrown into the bloody mud by the god of death, who did not forget to trample on them before leaving.

So when he heard that a young man easily inserted a tube into Shebasto's brain and successfully completed a craniotomy and drainage operation, Landreth's burned-out surgical heart seemed to be ignited again.

Kavey Hines, the man who started the fourth phase of his career.

Landreth knew that he was different from Cediyo, and his lack of experience was fatal. His surgical talent alone was not enough to help him complete the operation. So when he heard that Kawi was going to perform a craniotomy, he said he would do it, but his hands and eyes were honest, and he immediately began to cram for brain anatomy.

But anatomy is anatomy, and surgery is surgery. The theory and the actual situation are as far apart as the Atlantic Ocean. They are two completely different things.

Over the years, he had read through books on cranial anatomy and several books specifically on cranial surgery. Even with Sedillo's oral description and the actual autopsy results, it was still a little bit lacking. Landreth still couldn't imagine the scene of the operation.

It was not until he saw blood spurting out of the small arteries after the scalp was cut, the bone drill and wire saw grinding out bone powder, and then the pedal-operated roller micropump aspirator with a diameter of less than 1 cm carefully sucking out less than 2 ml of blood, that he deeply realized what it felt like to cut open a living person's head.

Landreth flipped the flap and secured it to the surgical drape with a spring hook, tucking a gauze roll underneath for padding to prevent excessive angulation that could cause ischemia in the flap.

Drill a hole, insert the wire saw guide, insert the wire saw, grind it, and then use two periosteal strippers to gently lift the bone flap. This was Landreth's first time operating, and his skills and luck were in place, so there were no accidents.

"Turn again, keep turning." Kavi gestured upward to Landreth, asking him to turn the peeler in his hand from "一" to "丨". With a crisp sound of fracture, he called for a stop, "Okay, stop!"

After clearing the dura mater that was somewhat adhered to the inner plate of the bone flap, the two removed the bone flap. The next step was to cut open the dura mater, enter the subdural space, and look for the leak.

"When looking for leaks, don't be lucky and think you can find leaks outside the dura mater." Kavi warned everyone, saying, "It is better to look for leaks in the intradural space at the beginning, because the dura mater is closely adhered to the skull, especially at the cribriform plate. First, exploring outside the dura mater often causes new dura mater tears, which are difficult to distinguish from the original leaks.

On the contrary, if you explore the space below the dura mater, you can see the adhesion of brain tissue at the leak, which is easier to identify. Give me a hook and the smallest suture needle and thread." Kavi gently hooked down with his left hand, lifted up a part of the dura mater, inserted the needle into the outer layer with his right hand, and then gently lifted the dura mater: "Cut it open with a scalpel."

Cavi's operation was clean and neat. He had done everything that needed to be done before using the knife. All Landreth had to do was turn the blade upwards and gently lift up the membrane, then use a pair of small scissors to cut along the designated cutting line.

"There's a lot of bleeding in the meninges." Kavi gently covered the torn dura mater with a cotton pad, then shouted to the outside of the door, "Where's Holmes? Is he back?"

Holmes' voice came from outside the door. "Coming, coming."

"Is everything ready?!!"

The door to the operating theater opened, and Holmes and two interns brought in a small charcoal stove. Next to it were several tweezers and a metal curved tray filled with ice cubes. "Alright! Everything is ready!"

After the rubber tube was delivered, Holmes had been preparing various things for the operation. The charcoal brazier and ice cubes were already prepared, and they only needed to be brought to the theater, but the tweezers were made overnight by a smelter on a whim. Although it was not difficult to make, it was just an ordinary copper-silver alloy, but someone still needed to go to the door to receive the goods.

Kavi glanced at it and said, "What about the other thing?"

"Yes, I put it in the kitchen first." Holmes couldn't imagine why Cavi's surgery required so many non-medical things, and he couldn't imagine what those things had to do with the surgery. "I'll let the chef know after the surgery is over."

"Chef?" Kavi frowned. "What chef? Hurry up and bring the food over. I'm going to use it later!!!"

"what???"

6◇9◇Book◇Bar

Holmes' body reacted faster than his brain. He turned around and was about to leave, but was stopped by Kavi. "Don't go. Let the intern go. You stay here and help Peon. There's too much bleeding in the dura mater. Hurry up and heat the tweezers and hand them to me!"

The moment he saw the charcoal stove, Landreth basically knew what Kawi was up to, but he was confused by the "thing" he mentioned. Landreth didn't like the feeling of being kept in the dark: "Thing? What is it?"

"Let's do the surgery first, and then we'll talk about it when the stuff comes."

In general, intraoperative bleeding is not much. If bleeding occurs, it can be compressed or sutured. There is no need to use red-hot metal wire to stop the bleeding. It is only in delicate locations such as the dura mater and small blood vessels in the liver that Kawi has to use this method.

At a time when electrocoagulation is not possible, burning is indeed the only way. The main reason why it is "necessary" is that the stove is too dirty.

In order to ensure that the surgical area was clean enough and that the temperature of the forceps was high enough to stop the bleeding, Holmes also brought in a screen and created a heating area next to the operating table.

"Sutures are not a panacea. High-temperature hemostasis, a method left by our ancestors, should not be abandoned. It can definitely have a place in surgery in another form."

Kavi took the heated alloy tweezers and first touched them lightly on the cloth gloves to test the temperature.

When he felt it was almost done, he gently placed it on the edge of the slightly raised dura mater incision, less than 5mm away from the brain tissue below. A faint sizzling sound was heard, and the dura mater began to contract. Seeing this, Kavi quickly removed the tweezers, gently touched the ice water, and then rubbed off a layer of black debris on the gauze: "The temperature is a bit high, shorten the heating time by ten seconds."

"it is good."

Cavi's self-created method of stopping bleeding amazed everyone, who exclaimed that this was how surgery should be performed. Landreth, who was standing by, was also very excited, but his face and mouth remained the same, as stiff as a sculpture that a freshman from the art school had just made: "Why use ice water?"

"In order to cool down and remove the high-temperature adhesive left on the tweezers," Kavey lamented, "I tried many kinds of metals and alloys, even platinum, to solve this problem. Unfortunately, it was useless and high-temperature adhesion still occurred. So I had to settle for the next best thing, instead of solving the problem of high-temperature adhesion, to easily wipe off the high-temperature adhesive, at least to reduce the steps of stopping bleeding as much as possible."

In the next few minutes, the forceps rotated between Cavi, Albaran, and Holmes, cutting and stopping bleeding at the same time, and finally successfully cut the dura mater close to the face side.

"Although epidural exploration is risky, entering the subdural space is even riskier." Kavi pointed to the center with the dissector, "The most common mistake is the superior sagittal sinus, which is the median dural venous sinus.

This was already mentioned during the craniotomy. In order to prevent accidents during drilling, I temporarily changed the drilling position from six holes to eight holes, so that the superior sagittal sinus can be avoided.
After changing the position, when cutting the skull with a wire saw, you must also be careful not to touch the superior sagittal sinus when passing through the cranial foramen. This is why when making a central cranial foramen, you should avoid the superior sagittal sinus while staying as close to the midline as possible.

Because once it deviates too much from the midline, the guide plate inserted into it can easily be inserted into the superior sagittal sinus, causing severe bleeding.

Before we open the dura mater and enter the subdural space to explore the leak, we also need to detach and ligate the superior sagittal sinus. This is a venous sinus that is attached to the underside of the dura mater and requires extreme caution when handling it. "

Free the area below the superior sagittal sinus slightly, then clamp the venous sinus with two smallest hemostats, then use a scalpel to open it from bottom to top and suture it with intestinal suture.

"After ligating the superior sagittal sinus, we still need to deal with the exposed frontal sinus. There are more bone holes and ruptured frontal sinus mucosa here. The gap is very large. It is impossible to use sutures or cautery. We need to use something completely new."

Kavi looked outside the door and saw two interns holding a fish tank, walking towards here carefully: "Holmes, change your clothes and help take it. Just put the water tank in the preparation area, don't go near here. Yes, okay, slow down. That's it!"

Kavi put down the tools in his hand, looked up at the puzzled audience, cleared his throat and said, "Now let me introduce the real protagonist of today's operation. It is a gift from nature from the Red Sea, enthusiastically recommended by Ottoman diplomat Mr. Hakan Merilal. The Arabian Gulf catfish."