Nineteenth Century Medical Guide

Chapter 408 404. The truth beneath the surface

Rochester sent Ayesha away and chatted with Mayer for a while. After making sure that the other party would not talk too much, he parted ways with him.

After leaving the tavern and quickly walking two streets south, Rochester waved to stop a public carriage that happened to be coming.

I don’t know whether it’s because the World Expo is approaching or because the tourism industry is developed enough, but the service attitude of the coachmen in Paris is much better than that in Vienna. Seeing that someone was about to get on the bus, the coachman tightened his grip on the reins and jumped out of the car. After collecting the money, he opened the door for Rochester, then climbed on the roof of the car and waved his whip.

Rochester didn't know where the carriage was going. He just wanted to leave this place as soon as possible and stay away from Cusper. Sitting on a crowded wooden bench, breathing in the turbid air in the carriage, I finally came to my senses: I actually lied.

He still can't believe he lied.

In his unfortunate life of more than twenty years, he told countless lies to his family, friends, women, children, and an old friend who didn't know where he was. As an old acquaintance of major casinos, lying has always been his tool and his way of making money.

However, this time, he was really scared, so scared that even though his body was sweating, his hands were still as cold as a dead rat that fell into the gutter.

Rochester cowered in his seat, secretly reached into his pocket and touched the two letters.

He couldn't help but secretly cursed himself for being stupid: "Rochester, are you stupid? You just handed over the letter, so why did you change your mind halfway? What's wrong with you, how dare you lie to those lunatics?"

It's all these two letters that are causing trouble! ! !

If there were no two letters, if I ignored them and threw them away on the spot, or if I had just surrendered and handed over the letters, let Cusper see my sincerity.

Rochester held his head in his hands, curled up into a ball, and all the negative emotions wrapped in the past in his heart overflowed. If I hadn't gambled the money and gambled the property title and company. If only I had stopped sooner, confessed to my father and asked for help from the beginning. If only I weren't so stubborn and not bewitched by that demon Laszlo

He didn't know how many times he had reviewed his shabby experiences. There were opportunities for maneuvers everywhere, but he missed them all. They lost all their land deeds and lost all their family property. A good hand of cards was played badly, so badly that he felt he didn't deserve to live.

The second letter is the same as the one Rochester received, explaining the purpose of the visit and showing that sinners can also atone for their sins. In addition to confessing in the House of Atonement, you can also take positive actions to erase your sins. 【4】

After clarifying the goal, even though Ayesha has never lied to others, her deception methods are no worse than Rochester's. He even learned how to mix truth into lies, and brought out his real threat - Nora.

Kalman claims to be an important member of the Hungarian 48 independent organization, and his position is self-evident. I found him because Rochester now has a very special status and has the opportunity to get in touch with core members of Austrian politics.

He knew the other party's intention in choosing him, and what he would face next was extremely dangerous.

Kalman's first letter was delivered to her six months ago. The content was as straightforward as Mick's, telling her and her teacher that they were both sinners, but they should not be treated like that by Mick. 【3】

The first letter was secretly handed to him via Gezer, which mainly explained the current situation of Rochester and the situation in Hungary, and asked him to contribute to the country. 【1】

Although she was a nun and her background was far less glamorous than Rochester's, her situation was similar and she was also caught by Mick and the others. If the matter is revealed, it may not be as simple as death.

In fact, a discerning person can tell at a glance that this is nothing more than jumping from one devil's claw to another, and the nature of the threat has not changed.

In fact, when she learned that she was coming to the tavern, she was prepared to die. Unexpectedly, the result was not bad, at least she got through it, and everything seemed to be developing as the letter said.

Unfortunately, things are far from that simple.

Until a week ago, she received the third letter in Paris.【5】

Ayesha also received the letter, even earlier than Rochester's, and it was also signed to Kalman.

Of course he could refuse. The other party did not use a "demanding" tone in the letter, indicating that it would not matter even if Rochester betrayed him. Maybe this is sincerity. When everything is put in front of him, it is naturally clear what to choose next.

It's a pity that the other party is also a human spirit and has no intention of helping. Ayesha was a little disappointed, but it was not a big problem. At least Kalman's letter and their action plan were not exposed.

Unlike Rochester, Ayesha does not like Vienna, which is full of filth, deception and oppression that she cannot tolerate. Of course, she also has no good impression of Paris, which is also authoritarian. It seems that except for Budapest, which is trying its best to resist freedom and seek freedom, other cities are covered with a veil of hypocrisy.

When Rochester showed no obvious resistance, the second letter sent recently revealed the identity of the other party. 【2】

But Ayesha was moved. Not only did she not report her, she also tried to write a reply to the other party. In the end, I had no choice but to give up because I couldn't find a contact person.

Both letters came from a man named Tisa Kalman, a well-known guy who had been in close contact with Mr. Deacre, the counselor of the two countries.

Perhaps this is why Rochester subconsciously wanted to keep these two letters, because the letters gave him the possibility of restoring the family's reputation.

This housekeeper is indeed an important obstacle that limits her actions. It would be best if she could be eliminated with the help of Cusper.

She now empathizes with what happened to her home country, and hopes to dilute her guilt by helping Mr. Kalman. So Ayesha decisively destroyed these three letters and made it clear that she would help.

Ayesha didn't see it as clearly as her dead teacher. She believed it and joined Kalman's organization by default. And through the help of the priest, he successfully sneaked into the Earl's Mansion.

Cusper and Mick are not fools, they just haven't reached the right moment yet. When it comes time to take action, the two lunatics won't hesitate at all.

Under this apparent "fact" there may be another fact hidden, just like Bertha lying far away in the operating theater of the Cathedral Hospital. Before opening her belly, almost all doctors were sure she would have internal bleeding. But after opening it, they saw another scene.

"There's not a lot of bleeding." Landreth carefully rummaged through the organs, which were several times smaller than an adult, and found only a small amount of oozing blood. "It's probably no more than 50ml."

"Maybe not even 30ml."

Landreth has completely regarded Kawei as his assistant, and Peang and Albaran, who came later, have become the second and third assistants: "Come, help check the liver again."

"I have checked it all with my hands. The surface is smooth without cracks, and there is no sign of bleeding at all." Kawei was very sure of his current judgment, but he had to doubt its authenticity, "The adult horse weighs at least 600 pounds. She was beaten quite a few times.”

(A brief aside, some readers mentioned the weight unit problem before, but I was negligent. Since then, they have all chosen to use the old Austrian scale instead of kg, and the numerical difference is not big.)

"Some people are just lucky, and there are many such people on the battlefield."

Although Landreth said this, he still carefully checked the condition of each organ for fear of missing any details: "Now it seems that except for a small rupture in the spleen causing a subcapsular hematoma, everything else is normal. "

"Even the step of compressing the splenic pedicle to stop bleeding is omitted."

"But the question is where did the blood come from?"

"The membrane surrounding the hematoma may be leaking, or there may be small damage." Landreth explained, smiling and taking the needle and thread from the nurse's hand, "Don't think so much, the anesthesia time is coming soon, and the sutures are broken. Mouth, close your abdomen as soon as possible.”

His explanation was correct and consistent with the fact that there was not much blood remaining. But Kawei just found it strange. His intuition from many years of emergency surgery was always unwilling to admit this fact.

"I didn't expect that after we fought for so long, we would end up with this result."

Landreth was relieved.

The six-year-old child's spleen and liver rupture and bleeding is really difficult. He is not sure that he will be able to do it well, let alone directly face critical situations such as massive bleeding that may occur during the operation. If the operation cannot be completed successfully, or if there are problems that cannot be solved during the operation, and Kawei comes to help in the end, then he will be really embarrassed.

The good thing about this surgery is that there was only one hematoma and the rest was basically normal.

"what happened to you?"

Seeing that Kawei did not help, Landreth asked: "The operation will be over soon, don't be lazy. Although it is only a rupture of less than 1cm, it can still kill people if it is not handled properly."

"I always felt like something was wrong."

Kawei helped pad the wet gauze, and then held out the spleen together to create a good suturing space for the surgeon: "I always feel that there is something that I haven't checked."

"All the internal organs have been examined." Landreth began to suture the ruptured wound. "You didn't even spare the bladder, so what else could be wrong?"

"It's a pity that I prepared too much blood."

Peang seemed very disappointed. He wasted too much time preparing blood. In the end, all he could see was the stitching of a ruptured spleen. Compared with this "minor surgery" that can be practiced on pigs or cadavers at any time, he still hopes to do something more challenging. A tear of less than 1cm was not a big problem for Landreth. He also padded the omentum and sewed it together according to Carvey's previous request. Three stitches were sutured, knotted, and threads were cut. Everything seemed to be done with ease: "Here, bring water and a suction device, and prepare to wash your stomach."

"Wait a minute."

As the operation came to an end, Landreth became a little impatient: "What's wrong with you?"

Kawei ignored him and stopped Albaran, then asked everyone present: "Her blood pressure has been unstable. Even by the standards of a 6-year-old child, it is low. It is far low." Below normal levels. If there is no reasonable explanation, her stomach will not close."

After saying that, he took off his gloves and put the ether mask on Bertha who was about to wake up again, without giving anyone else a chance to refute.

The three of them were confused: What’s a reasonable explanation? You even proposed the method of checking vital signs. Let us give you a reasonable explanation?

Peang could only explain with a superficial understanding: "Although the blood pressure was not stable at the beginning, after the fluid was added, the blood pressure has become normal. It is now 92/58, and the heart rate is also normal."

"Then where did the blood pressure that started to drop go?" Kawei held on to the blood pressure and said, "This must be the result of a loss of blood volume."

"Maybe the horses stimulated her mentally." Albaran secretly complained: "She was just scared."

Payon:? ? ?

Kavi:? ? ?

At this time, Landreth suddenly asked: "I wonder if Dr. Kawei has any understanding of medical theories outside the West?"

"for example?"

Kawi thought it would be something from Arabic medicine, or some rhetoric from ancient Egypt or ancient India, but in the end he used a set of disease and syndrome names that Kawi was most "familiar" but also "unfamiliar" to explain:

"Is it possible that her blood pressure was originally low and it was not caused by trauma? I see that her complexion is sallow and her body is thin. She should be deficient in both qi and blood. The reason may be that long-term hunger has caused the biochemistry of qi and blood to be inactive, thus lowering the blood pressure. Her original blood volume.”

Although some words had different meanings after being translated into French, Kawei could still understand them generally: "You actually studied Chinese medicine?"

"I studied under Professor Remusha and specialized in Chinese medical research." Landreth was very proud of his knowledge. "If it hadn't been for Mr. Holt's repeated invitations and the persuasion of my senior brother Julian, I might have stayed in Paris. The University and the Royal Library continue to complete the translation of Chinese medicine books.”

Kawei had heard about French Sinology, but he didn’t expect there to be a surgeon specializing in Chinese medicine: “I see.”

"I heard that Dr. Kawei is also very interested in Chinese culture." Landreth shook his head, "Forget it, now is not the time to talk about this. I don't know if you understood what I just explained. There are many unique features of traditional Chinese medicine. understand."

"I understand."

Kawei has also seen that people who have been malnourished for a long time have indeed lower blood pressure than ordinary people. But Bertha was different. Although she didn't eat well, she was far from suffering from low blood pressure: "Chinese culture is profound and profound, and this explanation does make some sense."

Landreth strongly agreed with this statement: "Then stop the anesthesia and close the abdomen quickly."

"No, you can't close your abdomen yet."

Kawei checked Bertha's reaction after anesthesia, then washed her hands and put on gloves again: "I just agreed with this statement because it is not wrong in itself. Unfortunately, it cannot be used on Bertha because of her malnutrition. It’s mild, far from hypotension.”

"What do you want to do?"

"I thought of another possibility."

"Every internal organ in her body was checked, and even her intestines were checked twice. There was no bleeding except for the spleen." Landreth also wanted to search for some other explanations to stop Carvey from continuing to torment the patient. "She is still She is a child with broken arms and large wounds, and her health is not good. Stop torturing her."

Kawei prepared several more pieces of wet gauze and spread them on Bertha's chest: "We just checked the internal organs, not the 'abdominal cavity' in the strict sense."

Landreth frowned and didn't understand for a moment: "What do you mean?"

"The abdominal cavity refers to the cavity within the abdominal wall." Kawei said a very simple anatomical knowledge, "The abdominal cavity is divided into three parts by the peritoneum. What we are examining is only the internal organs in the peritoneum, as well as the peritoneum. outside."

"Extraperitoneal?"

When Kawei said this, he added: "It should be called 'retroperitoneal space' more appropriately." [6]

Compared with traditional intraperitoneal organs, the kidneys, pancreas, duodenum, and ascending and descending colon in the retroperitoneal space often have nothing to do with blunt trauma to the front of the abdomen. Even trauma from the lower back will be borne by the spine and muscles first, playing a very good buffering role.

Therefore, the retroperitoneal space is not a common surgical area in general surgery.

The reason why Kawei could think of this was because all the major organs in the peritoneum were too clean. Further into the chest, the cardiopulmonary function was good, and no problems were seen. If there is a problem, it can only be in the retroperitoneal space.

Ruptured kidney?

The kidneys are protected by a large amount of fascia, and the organs in front are fine. It is almost impossible to rupture the kidneys.

Or is there something wrong with the pancreas?

More likely than kidney damage. However, a simple blunt injury to the pancreas will not cause a drop in blood pressure, but a severe injury will cause leakage of pancreatic juice, which can definitely be found during the exploration just now.

Could it be retroperitoneal hematoma?

No, retroperitoneal hematoma is mostly caused by pelvic fracture or rupture of large blood vessels. Such a severe amount of bleeding would inevitably lead to shock, and there would be no chance of a bumpy journey to the hospital.

Kawe manually retracted most of the small intestine, exposing the retroperitoneum.

It was just a simple exposure without incision of the peritoneum, and the sight in front of them shocked everyone. Peang couldn't help but ask: "What is this? Why don't I remember that there is such an organ in the retroperitoneum?"

"Is it a tumor?"

What Albaran accidentally said was true, but only half true. Landreth took a breath, lowered his voice, and corrected: "It's a hemangioma."[7]

To the two young doctors, this was an extremely unfamiliar word. Only surgeons with rich experience like Landreth may have come into contact with it, but only from books. Because all the operations that try to make people think about it end in failure.

In modern times, abdominal aortic aneurysms caused by trauma like Bertha's are often a special type of hemangioma, generally called abdominal aortic dissection.

Kawei must have seen and performed this kind of surgery, but traumatic aortic dissection at such a young age is really rare.

Moreover, Bertha was too young and her physical foundation was not good. What's more terrible was that there were no conditions to support this kind of surgery in the 19th century. It’s not just the lack of assistants, lack of anesthesia capabilities, and lack of supportive treatment, but also serious deficiencies in hardware.

"How could this be?"

Kawei sighed and briefly introduced the cause: "Because the abdominal cavity is violently squeezed, the intra-abdominal pressure rises suddenly. This pressure further squeezes the abdominal aorta, causing the intra-arterial pressure to rise. If the ultra-high-pressure blood flow encounters When the lining of blood vessels is torn apart, it will look like this."

After speaking, he compared a stack of gauze to the blood vessel wall and the removed upper layer of gauze to the intima: "Blood entered between the media and intima of the blood vessel wall, forming a neoplastic expansion."

"The damage is so exaggerated, what should I do?"

The two young assistants looked at Kawei and Landreth. Landreth now had to look at Kawei: "Dr. Kawei, we finally found the cause of the disease. What should we do next?"

Yes, what should I do? When the answer after probing for a long time was in front of him, and it kept pulsing slightly, Kawei also wanted to know what to do.

(End of this chapter)