Nineteenth Century Medical Guide

Chapter 502, Chapter 498: Let Me Do My Nails
Chest urination is a very rare condition.

The main reason is that there is a thick diaphragm in the middle of the thoracic and abdominal cavities, the pleura in the thoracic cavity, and the peritoneum in the abdominal cavity. In addition, the kidneys are surrounded by fat and are fixed by a large number of ligaments.

Generally, when there is a problem with the kidneys, urine leaks into the abdominal cavity, not the chest cavity. Even if there is a problem with the diaphragm, urine will first enter the abdominal cavity and then overflow into the chest cavity.

This is Bergett's view, which is already quite good, surpassing that of most surgeons of this era.

In 1968, Italian physician Corriere first reported that urine seeped into the pleural cavity from the retroperitoneal space, causing pleural effusion (urinary pleural effusion), and explained the underlying mechanism.

The main causes are urinary tract obstruction (24%) or injury (76%), which leads to the accumulation of urine around the kidneys or leakage into the perirenal area and even the entire abdominal cavity, and then into the thoracic cavity through the diaphragmatic lymphatic passage, causing urine to accumulate in the thoracic cavity.

Before this, Bergette's understanding was considered ahead of its time, because it was indeed necessary for the abdominal cavity to be full of urine before it would leak further into the chest cavity.

It's truly rare to see someone like Ugo, whose abdominal cavity doesn't have any fluid accumulation and whose urine leaks directly into his chest cavity.

"It's because the violence caused a sudden increase in the pressure difference between the abdominal and thoracic cavities, which damaged the diaphragm due to the excessive pressure, resulting in a tear. At the same time, the violence also affected the tissues around the kidneys, causing them to move out of their original position."

"Huh?" Bergett looked at him with a "you can do that?" expression.

Kavi made a ring with one hand and inserted his fist into it with the other: "The kidney got stuck in the hole in the torn diaphragm due to the pressure, forming a diaphragmatic hernia."

Dislodging the kidney from its original position is equivalent to violently pulling on it, causing a tear in the renal pelvis. The tear then extends into the chest cavity along with the kidney, allowing urine to enter. The kidney itself may also be damaged, as may the blood vessels surrounding the renal pelvis.

"Diaphragmatic hernia?"

"The diaphragm has three openings, so it's normal to have a diaphragmatic hernia."

In Bergert's view, groin hernia repair is a major challenge on the path to becoming a surgeon. Other hernias, generally abdominal wall hernias and lumbar hernias, are also difficult to treat; hiatal hernias, which are also a type of diaphragmatic hernia, only appear in Kavi's introduction.

"Is this the hiatal hernia you mentioned before?"

"They are different. One is the esophageal cardia or stomach, which enters the thoracic cavity through the esophageal hiatus. This is caused by trauma that damages the diaphragm, allowing the kidneys from the retroperitoneum to enter the thoracic cavity. Of course, diaphragmatic hernias caused by trauma are more commonly caused by the stomach."

Kavi recounted a previous case: "I encountered two cases when I was a child, both involving children, both with injuries from being run over by a horse-drawn carriage. One had a right flank, very little urine output, and difficulty breathing, just like Mr. Ugo. The father opted for conservative treatment, but later he occasionally experienced hematuria, and his breathing difficulties continued to worsen."

He ultimately risked a thoracentesis, draining approximately 300ml of fluid, which changed from red to yellow and had a urine-like odor, easing his breathing difficulties. However, his condition worsened again after half a day, and repeated drainage failed to improve his condition; he ultimately did not survive.

Bergert could already guess what would happen next: "It's been dissected?"

“Yes, the autopsy revealed a ruptured diaphragm with a kidney lodged in it,” Kavi explained. “However, the cause of death wasn’t a diaphragmatic hernia; there were other injuries in the body that we didn’t find. There was also a post-traumatic infection that we couldn’t control.”

“The child is indeed difficult to handle. He has a poor physical condition and often gives irrelevant answers to questions.”

Kavi continued, "Another case involved the left flank, with lower back and abdominal pain, significant abdominal distension, and hematuria. Initially, there was no difficulty breathing, but after a month of treatment at a hospital, breathing difficulties began to appear."

The hospital was completely helpless; we were ready to go home and wait to die, but someone recommended my father's clinic, so we brought him here. We performed a biopsy, draining 400ml, and the condition improved with each repeated biopsy. After three days of this back and forth, we decided to have surgery.

Bergert now has a lot of surgical experience and is gradually understanding the nature of surgery, knowing that surgery requires thorough preparation to be completed.

The risks involved in performing surgery on people like Kavi and his father without any preparation in an attempt to save their lives are self-evident.

"It wasn't entirely unprepared; he performed several autopsies before the surgery and considered ways to handle this situation."

Kavi glossed over the countermeasures.

"The child had a ruptured left posterolateral diaphragm, a ruptured left kidney, a ruptured renal pelvis, and a ruptured renal artery. It was quite serious," Kavi briefly recounted the surgery. "The surgery was successful, but there were still some problems with the surgical method, and the local hospital dragged it out for too long, so the child didn't make it through."

Bergert found it simply amazing.

Given the complex thoracolumbar anatomy, it is necessary to consider the incision site, determine the anatomical dissection and repair suturing techniques in accordance with the healing capacity of each tissue, and adjust the nursing plan according to the patient's postoperative recovery.
This is something that cannot be mastered by simply performing a few dissections.

In other words, if surgery can be completed under these circumstances, it means that preparation has long been integrated into their daily work and has become instinctive.

Think about Antonio. He had Cavie's atlas, detailed case analyses, and specific surgical precautions. In the end, he still spent a long time preparing in the dissection room before daring to start.

This doesn't mean he's bad at surgery; in fact, Antonio's skills are quite good, above average.

His approach is exactly how a normal surgeon should handle an unfamiliar surgical procedure.

Berget couldn't help but sigh, "Without Cavie, it would have taken him at least a decade to catch up with Antonio's current abilities, given his talent."
The longer he followed Cavill, the more interested he became in Italy: "Lombardy is a magical place."

"Ok?"

“I never thought Italy… well, it should be back in our hands now.” Bergett recalled the outcome of the negotiations between the two countries after the Austro-Prussian War. “If I have the time, I’d really like to go there and take a look.”

Kavi immediately tensed up: "It's just an ordinary little clinic. We don't even know if it still exists after all these years."

"It should be there."

"There have been so many years of fighting in that area, the villages might not even be left."

Seeing that he was about to say something more, Kave quickly steered the conversation back to Ugo: "Let's talk about our Spurs player, Mr. Kave."

The two chatted idly at the foot of Ugo's bed, discussing two cases of urinary tract infection that were similar to his own.

Judging from his injuries, he and the other two children were very similar. They all experienced difficulty breathing after external injuries, and urine was drained. The doctors who treated them were also Kavi and his father, so the results can be used as a reference.

Ugo felt a tightness in his chest, his teeth clenched tightly, and all the muscles in his body were tensing: "Am I going to die?"

"Don't be nervous." Kavi had a bad feeling. "Those were surgeries from more than ten years ago. Medicine has advanced very quickly."

“But,” Ugo’s face grew paler, “I really regret it, I regret not staying in the square a little longer.”

“Hold on a little longer?” Bergett found it strange. “If you hold on a little longer, you’ll die.”

"Yes, it's better to die in the bullring than in a hospital!"

The light in Ugo's eyes had vanished, as if he were facing a bottomless, stagnant pool. He stood shakily by the water's edge, his toes already touching the surface; one more step forward and he would fall in.

Kavi felt something was wrong and thought of Anders again, so he quickly called a nurse: "Mr. Ugo is not in a good mood, get him some wine."

"Wine?" "Any kind of wine is fine."

Kavi needed to calm him down, at least until he was anesthetized. If he became as emotionally unstable as Anders, things would really get complicated: "Mr. Anders calls you a warrior; a scalpel is much safer than bull horns."

Having learned from his experience dealing with Anders, Bergett became more vigilant, slowly moving from the foot of the bed to the bedside, ready to deal with any possible loss of control.

The most dangerous item is the drainage tube. These long, thin tubes, which restrict a patient's movement, are the easiest targets for venting frustration. Ugo already had a ruptured chest cavity and a diaphragmatic hernia with a stabbed kidney; if he were subjected to further violent pulling...
Bergert is not like Kavi; he doesn't want to spend the whole night in the operating room.

Ugo held his breath, listening to the clatter of the nurse's shoes as she approached, then took the glass full of wine, a feeling he couldn't quite describe welling up inside him.

Feeling melancholy, unease, and a touch of fear and helplessness.

Anders' statement was clearly an overstatement; he may appear calm, but his mind is a jumble of thoughts.

This is not his fault. His condition, which could have been cured by lying down, suddenly slid into a situation where surgery was necessary, and the surgery was particularly dangerous. No one could have remained calm in that situation.

He took two sips of the wine, the sour taste flowing down his throat and into his body, but the so-called courage did not materialize.

Ugo leaned forward, raising his hand to reveal his fingernails, from which some dirt and sand could be seen: "I don't think a scalpel can compare to a bull, but... I'm willing to trust you this once. If possible, could you let me trim my nails?"

Bergert and Kavi exchanged a glance, wondering why he had done this. However, neither of them objected; as long as he was willing to undergo surgery, everything was negotiable.

“I always get my nails done before I go on the field. Maybe it’s a hint, but I always feel like it helps me hold the reins tighter and have a firm grip on the bayonet.” Ugo stroked his chin and smiled awkwardly. “Hopefully, it will bring me good luck.”

The renovation of the San Mattia Foundation Hospital cost a lot of money, and its infrastructure is among the best in the entire Basque Country; at least for now, it appears to be a success.

But if you put it in the context of the whole of Europe, it's not enough.

A surgical theater requires not only a surgical theater, but also supporting facilities such as an instrument storage room, a cleaning room, an instrument sterilization and preparation room, a preoperative patient rest ward, a postoperative recovery ward, and so on.

There aren't that many categories here; everything has been crammed into the surgical theater.

So patients like Anders, who have just undergone surgery, should be sent to the recovery ward for continuous monitoring of their anesthesia level and vital signs. Instead, they are simply left in the corridor leading to the back door, waiting to wake up.

Ether does not have the strength of modern anesthesia, and the respiratory depression is skillfully maintained within a safe range by cavitary techniques.

As the effects of the medication wore off, he regained his senses.

The air-like body gradually gained a sense of reality, and it floated lightly onto the clouds.

Color appeared in the pure white world—a blurry straight line with a clean, pale blue hue, slightly transparent, stretching endlessly from one end to the other.

Slowly, the clouds carried him downwards, their speed increasing, the blue line expanding continuously. Until they crashed into the gloomy, turbulent sea, the clouds transformed into a giant ship, and the straight line became the distant horizon.

Giant waves crashed against the hull, and the cold, sharp seawater stung his cheeks. His previously dull and monotonous senses had become extremely acute.

Finally, I heard a sound; someone was talking or singing.

It must be singing, a simple, clichéd boat song. It's mixed with various dialects and has no standard intonation, but the rhythm is very pleasant, making one feel relaxed and full of energy.

Excited to experience another kind of thrill, Anders shook the iron railing in his hand and shouted that he would set sail to conquer the sea and the world.

"Stop shaking!"

Everyone laughed, though it was unclear who was laughing, or whether it was mockery or hearty laughter; they all laughed nonetheless.

After so many years of ups and downs in the bullring, Anders was used to it all. Nothing else mattered; what mattered was that the ship was moving forward, relentlessly advancing towards the distant horizon.

The air there was filled with the azure of the sea and the radiance of the sun, and the air was thick with the scent of the sea... well, it didn't quite smell like the salty, damp smell of the sea.

He vaguely heard someone say, "Yes, breathe, breathe hard."

Anders' vision was blurry, and he did whatever he heard instinctively. When others told him to breathe deeply, he breathed deeply, trying to draw all the air into his nose.

This doesn't smell like seawater at all; it smells more like crushed rosemary that's been soaking in a large bottle of vinegar for weeks.

That sour and astringent sensation rushed into his nasal cavity, forced open his throat, and instantly filled his entire chest cavity, as if it wanted to thoroughly knead and marinate both of his lungs.

Cough cough cough~~~
"He's awake, he's finally awake."

The nurse tossed the revival needle aside and gently patted the back of his hand: "Let go quickly, this is an IV line. If you keep squeezing it like this, the medicine Dr. Kavi prescribed won't work."

Medicine?

Light blue?

Once he could see things clearly, his consciousness instantly returned to Anders' mind; everything that had just happened was an illusion.

The horizon is fake, the clouds are fake, and the ship is fake.

He loosened his grip on the IV stand and touched his face, finding a few drops of blood. Even the waves lapping against his face seemed fake.
Once Anders' vision was processed by his brain, the matching senses of smell and hearing also returned to reality.

"It's entered the chest cavity; there is indeed a tear in the diaphragm."

"Come on, the pressure plate is in place, get the field of vision clear. There's bleeding, where's the hemostat? Don't just stand there, stop the bleeding quickly!"

"It must be that blood vessel from before. Your separation was too rough. Did you clamp it? If you did, just ligate it off."

"Bring five more damp gauze pads!"

Anders struggled to move his head and could barely make out the doctors in black leather skirts and white masks gathered around the bed: "Who's here? Who's performing surgery?"

"Awake?" Kavi glanced at him. "Check your blood pressure and report your heart rate."

"I was just tested two minutes ago, and everything is normal."

"Give me hemostats." Kavi, who had been staring intently at Anders, now only had eyes for the kidney that had burrowed into the diaphragm. "If he's normal, just let him go, he's too noisy."