Nineteenth Century Medical Guide

Chapter 467. The Final Decision

After completing Fisher's surgery, Holmes' workload did not decrease. The frequent dressing changes became once in the morning and once in the evening, and the psychological comfort work basically disappeared, but was replaced by the complex care of the craniotomy incision and the secondary debridement of the eyeball removal.

The disinfectants used were boric acid developed by Cavi and iodine tincture that had just been brought to Europe from the United States, as well as gauze, cotton balls, and various clamping forceps. The wound was flushed with large amounts of saline and finally sealed with paraffin oil.

There is only one purpose, which is to ensure the cleanliness of the bone flap suture and the eye injury.

Each disinfection and dressing change took Holmes more than half an hour, and the entire operation was carried out while Fisher groaned in pain. This was a torment for both the patient and Holmes.

But there is no other way. Even in modern times when there are many kinds of antibiotics, relying solely on antibiotics is not enough. Large amounts of disinfectants and saline solutions are still needed for sterilization and disinfection.

The wound on Fisher's body was quite large and was already infected, and the bacterial reproduction had begun to accelerate before the operation began.

After thorough debridement, the infection in the eye socket was basically gone, and the development should be curbed by constant dressing changes. Although it is not easy to change the dressing at the frontal bone suture site, the sealing of paraffin oil during the operation has been done well, and it is still very clean.

The only worrying part left, which was also the problem from the beginning, is the brain.

Fisher had a fever before the operation, but it was not clear whether it was caused by infection of the eye socket wound or cerebrospinal fluid rhinorrhoea. Now that the operation is over, his temperature has risen to over 39 degrees instead of falling. In the morning, Kawi made the final diagnosis that it was a suppurative infection in the brain.

There are three reasons why it is a purulent infection.

First, it is based on experience, because postoperative infections are almost all purulent infections caused by bacteria. Second, the intracranial pressure measured by lumbar puncture, and increased cerebrospinal fluid pressure are signs of purulent infection. Third, the white blood cell count of the blood and cerebrospinal fluid, a white blood cell count much higher than that of ordinary people indicates a purulent infection.

[White blood cell counting method: dilute the blood 3 times with 20% acetic acid to dissolve all the red blood cells in the blood, then drip into the white blood cell counting pool, count under a microscope, and find the number of white blood cells per cubic millimeter of blood. (It would be more troublesome in the 19th century without a counting pool)]
Cavey could handle the diagnosis, but he couldn't handle the concept of "infection". Before Koch brought out his research results to popularize the concept of microorganisms to all doctors, Cavey still had to use the awkward "encephalitis" to explain this phenomenon.

However, he was very confident in his cranial closure technique and was confident that he could solve Fisher's intracranial infection. However, this process was very long and required the patient's physical fitness to cooperate, and the nurses to stick to it day and night to ensure postoperative care while maintaining his body's nutritional needs, otherwise it would be very likely to fail.

Holmes still remembers the surgery yesterday afternoon vividly.

Checking the location of rhinorrhoea, craniotomy method, preparation of repair materials, response measures for various special situations, and the final craniotomy technique are all key points and difficulties. Any mistake or omission will lead to failure of the operation.

But what Holmes couldn't understand was the final hurdle.

Checking the location of rhinorrhoea and the craniotomy technique can all be attributed to Cavi's sophisticated anatomical skills, his extensive knowledge of repair materials and his rich surgical experience can be attributed to his rich coping methods. These are all basic skills or fantastic ideas that others would never or dare to think of, but the principles are not difficult to understand.

Throughout the entire operation, the only thing that was very strange was the "layered drainage" that Cavi used at the end.

As soon as the hole at the skull base was blocked, three tubes were left on the surgical wound. No one could explain the principle behind it.

However, after repairing the skull base fracture, when almost everyone thought the operation was over, Kekawi still focused all his attention on closing the cranial cavity, because only he knew that repairing the fracture only solved the cerebrospinal fluid leakage, and the technique of closing the cranial cavity could determine the prognosis of postoperative suppurative intracranial infection.

Fisher had a purulent intracranial infection from the beginning, which is more deadly than postoperative infections in ordinary surgeries.

Since disinfectants cannot enter the cranial cavity, craniotomy cannot be solved by long-term dressing changes like Devinck's fracture wound. Because of the blood-brain barrier, even with antibiotics, it is difficult to completely curb the infection in a short period of time. Even in modern times, there is a 30-50% mortality rate, not to mention the naked 19th century.

The patient's body temperature fluctuates, the bacteria and immunity fight each other, the infection period will become longer and longer, and finally a large number of drug-resistant bacteria will be produced, and the outcome is still death.

Therefore, from the very beginning, Cavi set Fisher's postoperative mortality rate at around 50%. No matter how successful the operation was, whether he could survive would still depend on infection and a little bit of luck.

The reason why it is 50% instead of 100% is because he has the technology of "layered drainage".

"Layered drainage" is a concept first proposed by Professor Fu Jidi's team at the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences. It is a special treatment plan for suppurative intracranial infection after craniotomy.

Kavi had heard of this treatment plan before he traveled through time. During the Austro-Prussian War, there had been dozens of attempts, which reduced the mortality rate of open craniocerebral firearm injuries from 100% to 63%. Now that he was at the Palace Hospital with complete equipment and staff, the chance would be even lower.

Because of this technology, he had the confidence to open Fisher's skull. After repairing the skull base fracture, he chose to perform three layers of negative pressure drainage: subdural, epidural and subcutaneous.

However, the delicate brain is not a rough place like the abdominal cavity. Inappropriate intracranial pressure will damage brain tissue, and the negative pressure of drainage needs to be corrected at any time. The size of the pressure is determined by the drainage volume and Fisher's feeling. If there is too much drainage or headache occurs, the pressure should be reduced to prevent the intracranial pressure from being too low. In severe cases, seclusion should be maintained for a period of time.

Of course, Fisher’s infection has just begun to break out. Bacterial infection will stimulate the production of cerebrospinal fluid and increase intracranial pressure. The drainage pressure should be higher to be more effective.

In Holmes' opinion, Cavi's layered drainage theory had no theoretical basis and was very mysterious. Unfortunately, the work of changing the dressing and flushing the tube took up most of his time, and he had no way to study it in depth.

"Mr. Fisher, are you awake?"

Fisher's eyes were stuffed with paraffin gauze, and his forehead was covered with thick gauze, which was then fixed with two layers of bandages. His body was burning hot, he felt dizzy, and he had no strength in his body. He could only give the simplest answer: "Uh"

"Dr. Peon and I are going to do the drainage and flushing. Please let me know if you have a headache."

Holmes held a syringe filled with saline solution, one end of which had been inserted into the thin rubber tube. Unexpectedly, Fisher, who had not been in high spirits just now, suddenly raised his hand and grabbed his wrist tightly: "Don't, don't do that this morning!!!" "I know, I was a little too fast this morning, I'm really sorry." Holmes smiled awkwardly, then couldn't help but look back at Peon and began to inject saline solution into the tube, "I will try to slow down. Tell me immediately if it hurts."

Fisher became nervous when he recalled the drainage tube flushing in the morning, so nervous that the back of his neck was wet.

He didn't know why just injecting a small tube of saline into his brain caused more pain than hitting his head with a hammer. He only knew that this kind of headache was something he had never experienced before, as if there was an evil ghost living in his brain that was constantly expanding and was about to burst his brain.

After being scolded by Kavey for his mistake in the morning, Holmes became extremely cautious and injected the saline very slowly.

After pushing 5 ml of liquid in, Fisher patted the mattress hard.

"okay, I get it."

Holmes gave up the push injection, unplugged the syringe, released the liquid that automatically flowed out, and then connected the negative pressure drainage. When the liquid in the negative pressure syringe was full, he started pushing the injection again. He repeated this process more than a dozen times, and only stopped when the aspirated liquid became cool and transparent.

As the saying goes, practice makes perfect. For this kind of work, once you practice it a few times and gain experience from failure, you will quickly master the trick.

After four or five puffs, Holmes was able to roughly grasp Fisher's tolerance dose and pushing speed. After a few more times, he basically tested the tolerance limit and began to speed up his hands.

Just as he was enjoying the changes brought about by technology, a familiar voice came from behind him: "Holmes, you are in the newspaper! The latest newspaper!!!"

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"what?"

Holmes had heard this sentence more than a dozen times throughout the day. When he first heard it, he would be excited and thank those who brought him the first-hand news, but now he was just bored and troubled.

Although it was troublesome, Holmes could not refuse others' kindness, so he could only stop what he was doing and look back. Unexpectedly, the person who walked into the ward quickly and shouted the newspaper news was James and Wade: "James and Wade? Why are you back again? Is the internal medicine rounds over?"

"Uh" James and Wade didn't care about that. After entering the ward, they walked to the bedside and said, "Hurry up and read the newspaper."

"What newspaper? When was this news? Didn't I just tell you about the operation?" Before he could finish his words, Holmes asked him to step back. "Hey! Wait a minute! This is the dressing and disinfection area. You can't come in without gloves or a mask! And you can't come in with the newspaper in your hand!!!"

"what?"

"What? If you have anything to say, stand behind the bed and talk! This is Dr. Kavi's rule!"

Zhan Wei had no choice but to step back half a step, stand where he should be, and point at the newspaper in his hand and ask: "Did you offend someone you shouldn't have offended during the operation yesterday?"

"Ah" seemed to have grown two legs, jumping back and forth in their mouths repeatedly. This time it was Holmes' turn: "Ah???"

"What? Your apology letter has been published!" James and Wade stuck their feet in place, trying to put the dried tofu in the corner of the newspaper under the light. "Did you see it? Your apology letter to the Minister of Economic Affairs."

If it weren't for James and Wade's reminder, Holmes wouldn't have thought he had offended Darnay. What's even more outrageous is that he didn't even remember what this guy looked like, so the most critical factor, the "apology letter", escaped the layers of screening mechanism during the brain crash and restart, and was easily skipped.

When he came to his senses and Danai's face slowly appeared before his eyes, Holmes realized that someone might have sent the letter in his place, and the matter had become a complete mess.

This apology letter was the "masterpiece" of Varela and Gregg, and Mayer must have contributed to the fact that it was finally published in the evening newspapers on the 30th.

They wanted to discuss it with Kawi, but the time for publication was tight, and the manuscript had to be finalized before noon. The next step was typesetting and printing, so there was no time for discussion. If they spent time looking for someone, they would be in a very passive position once Danai's letter was published.

At this time, it is very important to seize the initiative. Whoever appears first will occupy the readers' thinking high ground and make most people frame their thinking pattern. The letter that comes later will be treated as instigating according to this pattern. Darnay made a fatal move, so there was not much time left for them, and in the end it was just a draw.

Darnay's apology was published in the gossip supplement of Le Figaro and the temporary supplement of the small daily, while Holmes's was published in Le Soir de France and Le Nouveau Paris.

When the other editors compared the two letters that night, they realized their value. By the next morning, the two completely different apology letters had become freebies in the corners of almost all the best-selling newspapers, and it was hard to pretend that they had not seen them.

For a time, the whole city was in an uproar, and everyone was discussing the conflict between Danai and Holmes, and this conflict soon shifted to Kavey. No one would deny the surgical skills of this surgical genius, but if he relied on his own ability and acted too overbearingly, he would be caught in the whirlpool of public opinion.

The conservative Danai faction grasped this point, believing that everything from aristocratic etiquette to diplomatic relations between countries should not be like this. In a subtle way, they have already ignored Holmes as a tool and instead labeled Kavi behind him with various labels, in order to attack him for his "arrogance" due to lack of supervision.

Of course, there are also many people who are staunch supporters of the Kavey faction, who think that Danai, a spoiled nobleman, is looking for trouble. The operating theater should give way to surgical operations. If his recklessness really affects the operation, it will affect the development of medicine for all mankind.

The remaining centrists, who make up the majority, are basically in a state of watching the show. They don't care who is right or wrong in the whole thing, and the most interesting thing is the hand-to-hand combat between the two sides with blood on their bayonets.

It was not until the evening of July 7 that Le Figaro published an urgent piece of news that poured cold water on the rapidly heating up public opinion. It also set the tone for Kavi, who was caught in the storm of public opinion.

However, Kavi had no idea about this at the time. He had been immersed in the experiment of aortic vessel preparation, and his mind was only thinking about Bertha's operation.