Nineteenth Century Medical Guide

Chapter 464 460. Geniuses should be busy with geniuses' things
Kavi inserted the rubber tube into Fisher's nasal cavity, then pinched both nostrils shut, covered the open frontal sinus with gauze, and began to pump air into the rubber tube. Or, to be more precise, to blow air into it.

The operation is not difficult. Peon blew twice into the tube, and Kavi could see a string of bubbles.

"Be gentle. Slow down. Wait a minute. Pay attention to the lighting angle. The reflection hurts my eyes!"

Kavi looked at the saline solution that had calmed down again, and asked the nurse holding the candle to change her position: "Keep blowing, slower, yes, slower. Don't stop! Hold your breath and blow slowly. Okay, it's not bad now, keep blowing."

The oil lamp in the nurse's hand and Kavi's head kept changing positions, and finally the entire anterior cranial fossa was clearly visible. "Ladies and gentlemen, compared to the previous methylene blue test, the bubble test was quite successful. It seems that Mr. Fisher is still blessed by God. I can now clearly see that the rupture is located in the right cribriform plate, and there is no other leakage."

Everyone had been on edge since the operation began, and now they could finally breathe a sigh of relief. After the relief, they were greeted with applause that had been suppressed for a long time.

Unlike the continuous applause in the opera house, the applause from the surgeons who had their hands free was quite short. The operation was not over yet, and careful repairs were needed afterwards. How to repair was still an unknown area for them deep in the brain, and it was far from as easy as Kavey said.

"Because of the location of the cranial cavity, this method is only helpful for discovering leaks in the anterior cranial fossa. It is useless for the sphenoid sinus in the middle cranial fossa and the Eustachian tube thereafter."

Kavi gave a warning, then thought it might not work, and added, "However, I personally recommend that you do not try this method lightly before you are familiar with the use of methylene blue staining. Without a bright light source, bubbles are not as easy to identify as you might think. Sometimes, because of excessive concentration, you may ignore the brain pressure plate and damage the brain tissue."

Landreth watched as Fisher’s head became the vessel for the elementary school bubble experiment and couldn’t help but ask, “What if it’s the middle cranial fossa?”

"I don't know." Kavi answered without hesitation.

"what?"

"I'm not omnipotent. If it's the middle cranial fossa, I would probably close the skull and choose another approach at a later date." Kavi gently pushed open the frontal lobe and inserted a dissector into the gap, pressing against the place where the bubble appeared. "Bring the suction device over here and drain the saline."

Peon wanted to remove the suction device and the rubber tube in Fisher's nasal cavity, but Kavi stopped him: "Don't worry, it will be useful later."

Peon was quite confused at first, but after a while he remembered an important part of the gap repair surgery - "gap inspection".

Only after repeated inspections of the defect are confirmed, the operation is considered successful and the doctor can end the operation. This is true for the digestive tract, blood vessels, and skull defects.

The previously used foot-operated micro-suction pump was replaced with a hand-cranked wide-mouth bottle, and the warm saline solution that had just been injected into the cranial cavity was successfully drained. The stripper controlled by Kawi began to scrape the edge of the cribriform plate defect, removing the adhesion scars and granulation tissue around the gap.

Finding the location of the leak is equivalent to solving the most critical difficulty of the entire operation. At this step, it has actually entered the final stage. The next steps become more formulaic, showing the complete gap as much as possible, and then plugging the gap.

As an assistant, Landreth needed to open the surgical field for the main surgeon, Kawi, otherwise Kawi would have to open the gap and control the peeling machine to peel, which would be too troublesome. So he naturally reached out to the brain pressure plate, hoping to take over the job, and at the same time he could get closer to see how the skull base scar peeling looked like.

"Let me handle it myself." Kavi didn't let go and left Landres aside.

It’s not that he didn’t want the chief surgeon to gain more knowledge, but mainly because Fisher’s brain was too precious.

Now the brain tissue is surrounded by the dura mater and no longer directly contacts the pressure plate. Without the stimulation of the pressure plate, the probability of epilepsy will be much lower.

However, there are only 0 and countless epileptic seizures. Once an epileptic seizure occurs, it will be buried in the brain like a time bomb, and no one dares to say that it will never occur again. The stimulation of the brain pressure plate itself is gone, but the downward pressure still exists. The increased intracranial pressure will affect the brain tissue, and if you are not careful, epilepsy may be forced out again.

Of course, Kavey still trusted Landreth.

The next surgery had to be completed in this state. Scraping off the granulation tissue could be done with one hand, but repairing was not so easy. Kawi needed to increase the pressure of the brain pressure plate while checking the blood pressure and heart rate, and then change the strength of his hands based on the blood pressure and heart rate feedback from the nurses, trying to find a balance between expanding the width of the surgical field as much as possible and the body's reaction limit after the intracranial pressure increased.

It won’t be too late to hand the brain pressure plate to Landres after you finish your attempt.

In fact, Landreth was not to the point where he had nothing to do. He was still needed to prepare the materials to repair the leak at the end of the operation.

"Dr. Landreth, your skills would be a waste to support a brain compression plate."

Landreth: ???
Kawi explained: "Repairs require materials. You can't just break off the stripper in my hand and stuff it into the crack, right?"

"what material?"

“The best material to repair the human body is naturally the human body itself.”

Kavi's eyes moved from the skull to Fisher's thighs. "Please disinfect Fisher's thighs. Then take out a piece of muscle with a scalpel and cut it into a 1*1cm square. Then take out a piece of fascia, which can be used as a cushion for the skull base."

As he spoke, he pushed the mucosa around the cribriform plate defect downwards to leave a defect area. "Of course, you can also use muscle fascia from other places in the future, such as arms, chest, abdominal muscles or cheeks. This piece of muscle with fascia will be mixed with fish glue that still maintains temperature and stuffed into the defect area."

Such an efficient and stable repair plan attracted a burst of recording sounds.

While Landreth was making the incision on Fisher's thigh, Kavey began to process a periosteal flap. Although it was not easy to process periosteal flaps in the 19th century, Kavey gave up the idea of ​​using a complete periosteal flap and used muscle fascia as a cushion. But when suturing and fixing, it would be easier to use a periosteal flap as a suture edge. If it was sutured directly on the skull, it would require drilling holes in the bone plate, which was very troublesome.

Ten minutes later, the isinglass wrapped with muscle tissue with fascia was stuffed into the skull defect.

After the pressure was filled correctly, Kawi called the nurse to inject saline solution into the cranial cavity again and blow air into the rubber tube again. However, this time he couldn't blow as hard as before, just to ensure the most basic airtightness.

"The repair is in place. I didn't find any bubbles." Kavi slowly removed the long forceps, then took the trimmed fascia and laid it on the skull base, connecting it to the periosteal flap with sutures. "After laying the fascia on the skull base, we finally need to deal with the torn dura mater, which is also the last difficult part."

[This is a modern approach, where a whole pedicled periosteal flap is directly peeled off for complete coverage.]
In cerebrospinal fluid leakage, skull base fracture is the predisposing factor, and the dura mater tear caused by the fracture is the main cause. In order to prevent the recurrence of cerebrospinal fluid leakage and prevent the current operation from becoming useless, it is necessary to completely block the torn dura mater.

However, it is not easy to repair the dura mater in such a small area.

The brain tissue has been squeezed to the limit, and the space in front is also very limited. Subdural repair is obviously not feasible, as it is easy to touch the brain tissue. Epidural repair also needs to consider the brain tissue behind, and it is not advisable to risk inserting the needle. In this case, controlling the pressure of brain tissue and maintaining the position of the brain pressure plate have become the top priority. This is also the reason why Kawi was reluctant to give the brain pressure plate to Landreth before. Only the squeezing position that he has repeatedly tried is the most suitable position.

"We will first separate the subdural adhesions." Kavi opened the dura mater again and returned to the previous position. "We will find the rupture of the meninges and use the brain pressure plate to gently separate the adhesions and block them between the rupture and the brain tissue."

The whole process took less than 3 minutes, which was not too slow, but the part of the dura mater that was adhered was less than 1 cm. When Kawi's separation actions were evenly distributed into these 3 minutes, it seemed particularly long in the eyes of outsiders.

"Finish."

For the first time, the nurse took out gauze to wipe the sweat off Kavi's forehead, and also announced that Fisher had passed all the dangerous stages of the operation.

Ten minutes later, Kawi sutured the ruptured dura mater, and ten minutes later, Kawi sewed a fascia patch above the rupture.

After the suturing is completed, all brain pressure plates are removed and the suturing of the skull flap begins.

The closure of the skull remained unchanged, just like the operation of Shebasto. At this time, the dura mater had been closed, and only epidural hematoma needed to be prevented. There was no other danger, so Kavi naturally handed the lead to Landreth.

The whole operation process is like a symphony of ups and downs, bold and extremely delicate. Every step of the operation is full of deadly traps and difficulties that can lead to the failure of the operation, but correspondingly, every difficulty and trap has become a background board to highlight Cavi's superb surgical skills and divergent thinking.

The difficulty of this operation was far beyond everyone's imagination. If one had not seen it with one's own eyes, no one would have believed that this was an operation from the 19th century.

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Even surgical critics who often participate in surgical reports cannot accurately describe the height of this operation. Even if they use their decades of accumulated medical knowledge, they cannot reproduce this operation on paper in words.

Wonderful, superb, gorgeous, miraculous. Poor words are far less than the warm applause from colleagues. Only the endless applause like thunder can become the flowers and red carpet when Kavi bids farewell.

Kavi once again confirmed Fisher's vital signs, counted all the gauze, instruments and scalp clips, and then announced to everyone amid applause that the operation was successfully completed.

"President Holt? Why are you standing here?" Kavi was about to leave the theater when he saw Holt standing at the door. "There should be a special seat reserved for you in the auditorium."

"I just came."

Holt had never seen such applause in an operating theater, at least not in his memory. The phrase "competitors" also applies to surgeons. To be able to reach such a high level means that everyone is deeply impressed by his skills.

Looking at the audience members who stood up one after another and were reluctant to leave, Hott leaned closer to Kavi, as if he had also become the object of others' cheers.

"President Holt, is there something wrong with you?"

After the operation, Kavi slowly returned to his original state. His tense muscles completely relaxed, and a smile gradually appeared on his face. Seeing how enthusiastic Holt was, he felt a little embarrassed. He had received so many favors from others, so he should show some appreciation: "Just tell me if you have any questions. I'll help you in any way I can."

"It's okay, it's okay! What else can happen to me?" Hott also laughed, patted Kavi on the shoulder, and praised him, "The operation was amazing, absolutely amazing! The method of using bubbles to check for cerebrospinal fluid leakage stunned everyone on the stage, including me."

"These are all methods that we use as a last resort. Half of the success depends on luck."

“You are humble.”

Holt entered the theater during the second half of the operation.

He originally wanted to have a good talk with Kavi after the operation and briefly talk about Danai. Although the other party's behavior was stupid, he was the Minister of Economy and a descendant of the old aristocracy, so he still had a certain weight in Paris. Moreover, Hott was not sure about this guy's temper. If he was going to disgust him, he might as well warn Kavi.

But seeing that such a complicated craniotomy could be successfully performed under various critical circumstances, and that the American student was also the surgical assistant, Hott felt relieved.

A genius should be busy with what a genius should be busy with. To bother a genius with trivial matters is a dereliction of duty on the part of the stage builder.

Just handle it yourself.

After being "beaten up" by Hott, Danai left the Main Palace Hospital early under the sharp gazes of many people.

He still regretted it, very, very much.

He regretted why he didn't control his temper and why he had a conflict with the "doctor" who was performing the operation. Although he later found out that the guy was not a serious surgeon at all, he was just a lowly and rude American, whose status was even lower than that of an ordinary Parisian citizen.

Apart from adding some funding for education in Paris, such people are dispensable to the entire Paris.

Under normal circumstances, it would be easy to kill such an American. He could be sent to prison on all sorts of charges with a few tricks. When he was done, they would help him to make connections, make him willingly spend a large sum of money to bail him out, and finally send him on a cruise ship back to the United States with a "thank you"
It’s a pity that behind him is Kavi.

"What? Do you regret it now???"

Dana returned home only after the operation was over. In order to show the generosity of the Gabiadini family and to calm the situation, she had to donate a considerable amount of sponsorship funds to the entire surgery department of the Hôtel-Dieu: "In order to make that foreign student shut up, I spent an extra 3000 francs!"

"Why so many?"

"I'm just helping you clean up your mess!!!" Dana felt uncomfortable, but she couldn't say anything too harsh to the family's only cash cow. "Forget it, it's only 3000 francs. At least the reporters saw it."

Money was nothing to Darnay, what he wanted was face, but now both face and money were gone. He understood the press better than his sister, and a donation of 3000 francs was not enough to counter the conflict just now. His embarrassment might have become a press release sent to the editors' desks.

"No, we can't just let it go!"