Nineteenth Century Medical Guide

Chapter 462 458. Anxiety
In medicine, the word "sinus" in most cases refers to a cavity. The sinuses connected to the nasal cavity are composed of the frontal sinus, ethmoid sinus, sphenoid sinus and maxillary sinus. They are filled with air and are the most common cavities.

The "sinus" in the superior sagittal sinus represents the structure formed by the veins expanding and folding into the brain fissure. The lumen is irregular and the wall structure is atypical. It is mainly used to recycle blood and prevent venous blood from flowing back. It is filled with venous blood and is actually a cavity.

The frontal sinus is located between the inner and outer plates of the frontal bone. It is a pair of air-filled inverted triangular cavities with mucous membranes on the inner walls. It is connected to the nasal cavity through the nasofrontal duct. The secretions produced by the frontal sinus mucosa can prevent bacterial invasion.

The frontal sinus varies in size, and it is easy to cut the frontal sinus directly by cutting the frontal bone near the eyebrow arch. After the frontal sinus is cut, the cavity is directly exposed to the air, the bone is destroyed, and the environment inside the mucosa changes dramatically, which is very easy to get infected after the operation.

After the frontal sinus is opened through conventional craniotomy, the open frontal sinus needs to be blocked by filling it with bone wax or sealing the mucosa with gelatin sponge. If there is a microscope and suitable suture needles and threads, the pedicled periosteal flap can be peeled off to make delicate repairs to the mucosa.

Unfortunately, Kavi did not have a professional surgical microscope, and ordinary catgut and suture needles were not sufficient for this operation.

As a second choice, the only two options are the first two.

Bone filling is a more traditional method, with simple steps and materials ready for use. Kawi had been using it when he was young, and had also tried it on the old marshal's spine. The spine is not originally hollow, so as long as the filled bone is clean enough, there will be no side effects of infection.

The frontal sinus is different.

Bone is a foreign body to the frontal sinus mucosa. Using bone to block the frontal sinus mucosa can easily irritate the mucosa and cause inflammation. The chance of postoperative infection is definitely lower than without blocking. However, even in modern times with very complete disinfection, the incidence rate can still be close to 15%, which is really unsatisfactory.

The latter abandons bone and chooses gelatin sponge, which can be used for simple mucosal closure, and the effect is much better. But gelatin sponge is a synthetic compound, which is a sponge filter made of gelatin produced by collagen hydrolysis and other synthetic materials. According to the properties of synthetic materials, gelatin sponge is subdivided into many categories. Medical gelatin sponge is mainly used for hemostasis, tissue adhesion and cavity filling to prevent wound infection.

Fisher was in poor health. If he had bone filling, the procedure would be simple and the materials would be easy to obtain, but the chance of postoperative infection would definitely be higher than for others. If he chose the latter, the gelatin sponge used to bond the mucous membrane would be a problem. The chemistry of the 19th century was far less powerful, and if he wanted to use gelatin sponge, he had to make it himself, which was too difficult for Kavi.

He could explain what gelatin sponge was because, like the scalp clamp before it, it was used in emergency surgery, but he had no idea where it came from.

He is just a clinical surgeon and is only responsible for dealing with clinical problems. Biology, chemistry, physics, and even microbiology, which is closely related to medicine, are not his areas of expertise.

But as a clinical surgeon, especially an emergency surgeon in a top-level hospital, we have to fight fierce battles, and being able to adapt to changing circumstances is our basic skill. When we are short of materials, we use whatever we have, as long as it is beneficial to the patient.

Now that we don’t have gelatin sponge and cannot replicate this material, we can only look for substitutes.

Kavi has looked for many alternative materials. The Paris World Expo brought together the world's best and most cutting-edge technologies and products, giving him many choices, and this fish tank is one of them.

"Catfish is probably a very common aquatic species in Asia. These catfish mainly live in the mudflats of the Arabian Gulf. Similar to other catfish of the same species, each of its pectoral fins has an aggressive spike, and it will not hesitate to stab an enemy when faced with one."

Kavi glanced at the three catfish in the glass tank, explained the characteristics of catfish, pointed to the periosteal stripper in the instrument tray, waved to the nurse, and began to process the mucous membrane inside the frontal sinus: "But today I'm not going to use the catfish's body or spikes, but the thick layer of mucus covering its surface."

The audience was agitated again, and many people took up their pens to write down this passage. However, for doctors who specialize in clinical medicine, let alone writing it down, they didn't even understand the Latin name of "Arabian Gulf catfish".

University zoology and botany were just a formality, not rigorous enough to require memorizing all the Latin names.

Everyone looked at each other in bewilderment. Some people simply used a combination of common place names and the names of fish they thought of, such as "Arabian Gulf Barracuda", "Arabian Mudfish", and "Arabian Thorny Fish". Some people had never even heard of the place name "Arabia" that inhabits the "Arabian Gulf", so they directly wrote "fish with thorns" or "quite aggressive fish".

Some people are even too lazy to write such characteristics, and just mark the color or subjective feelings, such as "a kind of black fish" or "ugly fish", and then use a sketch to describe the general appearance of the fish.

This situation continued until Kavi finished explaining, and then someone raised his hand and asked, "Dr. Kavi, what kind of fish was that just now?"

Kavi didn't understand what the man meant by raising his hand, and thought he hadn't explained it clearly, so he said it again loudly: "Arabian Gulf catfish."

"We," the man who raised his hand said sheepishly, "we don't know how to spell its scientific name."

"Oh, that's how it is." Kavi looked around and found that many people had the same confusion, so he explained, "The scientific name is 'Arius thallasinus'. Arius is the genus of catfish, and thallasinus at the end is the root. In fact, I only learned about it after listening to the introduction of that Ottoman naturalist."

Seeing that Kawi was so humble and answered questions, many people started again: "How do you know that it can adhere to mucous membranes?"

"Yes, such an unconventional material, and the mucus on fish skin, is simply amazing!"

Kavi had already made up an excuse for himself: "I talked about it with an Ottoman diplomat. He said that my surgery can make the patient's wound heal as easily as the skin of the Arabian Gulf catfish. It's amazing.

In fact, this fish will secrete this mucus when it is attacked to help the wound heal quickly. Some local fishermen will apply this mucus to their wounds, which will heal twice as fast. But what I want to use today is not only its accelerated healing properties, but also its ability to stop bleeding and its adhesiveness. "

After that, Holmes, under his command, put on another pair of cloth gloves and fished up the fish: "The surface is really slippery. What should I do next?"

"Hold the fish by the head and use a clean knife to scrape off the slime that's clinging to its body," Kawi explained. "Be sure to pay attention to the fins as you scrape to avoid getting pricked."

Holmes had hunted and fished in the wild before, so dissecting fish was no problem for him. "Don't worry, this is much easier than controlling the temperature of the alloy tweezers! Besides, it's just a spike. It won't hurt..."

"The sting is poisonous."

".It's just a prick, it's not like it's not a prick, huh?"

Holmes didn't react for a moment, and neither did the audience, but everyone in the theater focused their attention on the only moving catfish. The catfish, held tightly in Holmes's hand, was swinging its slippery body, and its pectoral fins on both sides repeatedly slapped against the gloves, making a crisp "pa pa pa" sound.

"Ah?!" Holmes was anxious. He loosened his grip and the fish fell back into the tank. "Is it poisonous?"

"The stingers are connected to venom glands that produce a venom that causes much pain to fishermen in the Red Sea and the Arabian Gulf," Kavi explained. "They cause long-term pain, tissue edema, local muscle spasms, and in severe cases paralysis and gangrene. Why would you throw it back?"

The symptoms of poisoning emerged one after another, making Holmes feel unwell.

"Hey, what are you thinking about? Hurry up and scrape it!" Kavi urged, "If you wait any longer, the mucous membrane will be folded. How can I seal it without mucus?"

Holmes was a little entangled, but the thought only flashed through his mind and he quickly overcame it. Because the catfish in front of him is likely to overturn the current wound healing theory and completely rewrite the principles of trauma treatment. At such a historic moment, if he didn't do it, there would be many people who would do it. Everyone wanted to be the first person to scrape the fish skin.

Not to mention Peon and Albaran, even many other doctors in the audience wanted to help, including several pairs of eyes behind him. Those interns had long been uncomfortable with him, and if Holmes hadn't intervened in the surgical work a few days ago, they should have done all the preparations.

The slime on the fish skin was not as much as Kawi had imagined, and he scraped 3 fishes to get 10g. It was not a lot, but it was enough if he used it sparingly.

"Mix it with saline in a 1:1 ratio." Kawi had already closed one side of the frontal sinus and started to work on the other side. "Repeatedly shake it for 5 minutes and let it settle. Remove the clear liquid and slowly heat the remaining liquid to remove excess water."

"it is good."

"Remember to heat it slowly and stir while heating. I only have three fish in my hand. Don't burn them."

In short, the whole crude preparation process was completed without any problems. If time was not so tight, Kavi would like to filter it several times to remove the impurities. If the amount of mucus is large enough, it can be washed with alcohol and carbolic acid to disinfect it thoroughly, remove the denatured protein, and make the remaining into gel.

Unfortunately, none of these steps are performed, and slow heating can only be used to remove microorganisms as much as possible.

After all, it is a traditional method and cannot be completely clean. When filling the frontal sinus, the filling amount needs to be considered, otherwise the small amount of foreign matter left inside will also irritate the mucosa. But no matter what, it is much better than bone filling.

"The frontal sinus closure is complete, but it's a little slower than expected. Next we need to..."

6◇9◇Book◇Bar

Cavi was about to ask Albaran to continue giving Fisher ether, but Fisher actually started to move, which was 10 minutes shorter than the normal duration of ether anesthesia: "Hold his hands and feet, and quickly give him ether!"

Although he said that, Peon and Landreth were holding things in their hands, so they couldn't react in time. Only Kawi immediately used gauze to cover the dura mater and then stopped his raised right hand: "It seems that the effect of ether on Mr. Coachman is weaker than on others. We have to hurry up."

Five minutes later, the restless Fisher finally calmed down again.

"I have said before that the purpose of injecting methylene blue into the subarachnoid space is to determine the location of the rupture so as to find a suitable craniotomy approach. The purpose of cutting the dura mater is to find the defective part of the dura mater that is adhered to the brain tissue under the dura mater, so as to truly locate the gap of cerebrospinal fluid leakage."

Kavi explained the two most critical steps of the entire operation again, then gently lifted the dura mater to expose the frontal lobe of the brain tissue again: "Now is the most critical moment, sew me up."

He inserted the needle into the inner side of the dura mater flap below the frontal sinus, pulled it with a certain tension, and then sutured it to fix it on the surgical drape: "When the meninges are suspended, there will be bleeding. At this time, you can't use burning techniques to stop the bleeding. Instead, use the thinnest cotton pad under the meninges to prevent blood from entering the dura mater."

After the meninges are fixed and the surgical field is sufficient, the brain pressure plate is used to gently press the brain tissue downwards to expose the front gap as much as possible and look for leaks: "The action must be gentle. Although there is protection from the arachnoid and pia mater, squeezing the brain tissue itself will still have an impact on it. So the exploration speed must be fast."

However, at this moment, just twenty minutes after the third ether ingestion, Fisher's body began to move involuntarily again.

Landreth and Peon reacted much faster this time and immediately held down his hands and feet. It was still far from the time for him to wake up, and Caveton felt that it was not good. However, the operation had come to this point, and if he chose to give up now, all the efforts he had made before would be in vain.

"What's going on here?"

"It's epilepsy. It could be caused by touching, or it could be caused by squeezing that increased intracranial pressure." Kavi did not give up and chose to continue exploring. "How is your blood pressure and heart rate?"

"The blood pressure was high five minutes ago, 159/74, heart rate 95."

Kavi nodded: "Hold it down for me!"

"Ah."

Fisher was still twitching, and Kavey's brain pressure plate was further pressed down. A lot of subdural spaces were indeed exposed in the surgical field, and Kavey did see adhesions between the brain tissue and the dura mater. However, due to the infection, the adhesion range was much larger than he had imagined.

At this time, according to the previous surgical plan, methylene blue needed to be injected back into Fisher's nasal cavity near the cribriform plate, and the leakage could be clearly seen by the leakage of the dye.

But there had already been a shock, and methylene blue could no longer be used. At least Kavi didn't dare to take the risk again.

Now he had basically determined the approximate scope of the leak, and gently pulled out the brain pressure plate to restore the brain tissue to its original state. As the brain tissue rebounded, Fisher's limbs also stopped twitching.

"Everyone, I just did a subdural exploration. The adhesion is very serious. The approximate range of the leak has been found, but the specific location still needs an epidural exploration. That is to further separate the dura mater behind the frontal sinus, and then flip it down to completely expose the skull base fracture, find the leak and then repair it."

Kavi lowered the sutures hanging in front to the back. His movements were gentle, but his tone became heavier. “But the seizure just now told us that pressing down on the brain tissue would destroy Fisher’s nerve center. We may not have the opportunity to do a detailed exploration.”

No way to conduct a detailed investigation?

How do you find the correct leak?
How to fix it if you can’t find the real leak?

Suddenly, many people at the scene thought of "operation failure", a phrase that had nothing to do with Kawi. In the 20th century, when the average mortality rate of surgery was as high as 30-19%, it was normal for surgery to fail. Kawi was a human being after all, and the risks associated with such a complex craniotomy were probably unprecedented, so failure was normal.

But there are still many people who feel unwilling to give up. The complexity and precision of the previous surgical steps are amazing, and it would be a pity to give up like this.

Gradually, many people began to speak out for Kawi, hoping that the surgery would be carried out no matter what. Some people also felt that taking the risk of using methylene blue directly was the most appropriate surgical method at the moment, which was better than having epilepsy for a long time.

Soon there was another debate in the audience, but no matter what the outcome of the debate was, Fisher's life seemed to be the least worth discussing.

"What are you arguing about?"

Kavi put down the brain pressure board and did not touch the methylene blue or look for other instruments. Instead, he chose the rubber tube and a ball of wet gauze soaked with saline that Holmes had taken earlier. "I didn't say I wanted to give up the operation, and I certainly didn't want him to die on the operating table."

(End of this chapter)