Acute Abdomen

"Name?"

"Gris."

"No, I mean the child's name. How old is she?" Kraft quickly wrote Gris's name in the section for family members, noting that he was the patient's father.

They were sitting in an empty classroom. Lucius had been sent to find a couple of blankets, since lying on the hard bench would be uncomfortable for the patient. The students who had followed them were held back, leaving plenty of space.

The paper in Kraft's hand had been taken from a stack of copy paper, with volume two of Human Anatomy underneath it. A student beside him had thoughtfully handed him an ink bottle. The pen raced across the page, the words flowing together in a stream.

Kraft's handwriting was quite good, but his notes during consultations were always crooked and messy. He didn't know whether some mysterious force was at work.

"Lis. Her name is Lis." Gris answered Kraft's questions softly and quickly, looking nervous and afraid, as though Kraft would stop helping if he took too long. "She's three."

The crowd of black-robed men had put him under considerable pressure. They'd stepped back when asked, but the bright classroom still seemed to have taken on a more sinister, frightening atmosphere.

"What's bothering her?" Kraft asked, turning to glance at the child lying across the bench. It was hard to tell the sex of a child this age without being told. Thinking back, he had indeed sometimes seen this child at the tavern, but the plain clothes had led him to assume she was a boy.

At the question, Gris looked as if he were about to burst into tears. His eyes were red, but he kept his emotions in check and described what he knew as clearly as he could.

"She seemed to have eaten something two days ago, and she's had diarrhea ever since. I thought she'd get better after a few days, but this morning her stomach started hurting even more. She can barely get a few words out."

"I took her to the church for some holy water. I also took her to a clinic, where they gave her herbal soup, but it didn't help."

"What herbs were in it?" Kraft pressed. He knew about holy water: purified water that had undergone a few strange rituals. He'd drunk it as a child, and as a placebo, at least, it was harmless.

Herbs were another matter. Few of the doctors running clinics outside the Academy had graduated from the Academy. All kinds of folk remedies and bizarre treatments were rampant, and they'd put anything in a medicinal soup.

This wasn't traditional Chinese medicine, with its pattern-based approach to diagnosis and treatment. The way Wenden Port's amateur doctors treated people was less like medicine and more like the way certain green things that grew out of the ground might be treated. Their guiding principle was basically, "I reckon this'll work."

"Sorry, I don't know..." Gris looked lost. "The priest said this happened because I didn't believe in the Lord with all my heart. Was I wrong to give her the herbal soup?"

The middle-aged man clutched at his head in anguish, nearly pulling his hair out. To him, this was a harbinger of death. He might lose his only child.

"I didn't mean that." Kraft put a hand on his shoulder, trying to calm him down. "It's all right if you can't remember. I have some other questions for you."

Gris was, it had to be said, the kind of parent doctors liked best. Despite his fear and panic over his daughter's condition, he was quite composed, and Kraft was able to get a fairly complete history from him.

The patient was Gris's three-year-old daughter, Lis. Two days earlier, she had suddenly developed a fever and diarrhea, with stools as watery as water.

This wasn't unusual. It was perfectly normal for a child that age to eat something that upset her stomach. Most parents wouldn't give it much thought.

As a father who paid close attention to his child, Gris had even made time to pray at the church and bring her some holy water.

But a day after drinking the holy water, little Lis hadn't improved. Worried, Gris took her to a nearby clinic, where a doctor prescribed a dose of herbal soup.

Despite the strange color of the medicine, Gris decided to let Lis try it. The result was a case of "try it and die." Early that morning, Lis's mild stomachache had rapidly worsened. She'd passed very little stool, and what came out was tinged with blood.

In a panic, Gris had carried Lis to the church and the clinic. The priest had said the only thing to do was pray earnestly and wait for the Lord's will. The clinic doctor had been just as helpless and had only wanted to avoid taking responsibility.

Having run a tavern beside the Academy for years, Gris had finally thought to ask for help from people he knew there. Otherwise, all he could do was wait and hope Lis would somehow recover on her own.

"I need to examine her. Is that all right?" Kraft finished writing down the history of her present illness and the basic information. There was little to add about her medical or family history. He knew only that Lis's mother had died of an acute illness, though Gris couldn't say what it was. Lis herself had never suffered any serious illnesses.

"Of course. Thank you." Gris nodded quickly. He didn't understand why Kraft needed his permission for this, but from Kraft's manner, it seemed he was going to take over the case.

"I mean a full examination. I'll need to touch her entire abdomen, including her groin." Kraft glanced at the students behind him, deciding he should explain first. "I don't think it's appropriate for so many people to watch. Gentlemen, could you step outside for now? You can use the time to review why I asked all those questions."

"Um... all right." Gris hesitated, then agreed, preparing to leave with the students. Kraft's serious manner must have earned his trust, because he didn't ask any questions.

"Gris, come back. I meant them. The family should stay with her and help keep her calm." The students quickly filed out. Kraft led Gris to the child's side and began the examination.

Kraft brushed Lis's hair aside and felt her forehead. Her temperature wasn't high. Her face was streaked with tears. She wasn't crying, probably because she'd been crying for so long that she had nothing left.

He already had a rough idea of what was going on. This was one of the things diagnostic medicine loved to discuss: acute abdomen. In plain language, it meant "Doctor, my stomach hurts." Even without his extraordinary memory, Kraft could apply what he'd learned with ease.

A three-year-old with two days of diarrhea and fever most likely had a gastrointestinal infection caused by a pathogen. That was common in Wenden Port, where seafood was everywhere.

But there was probably more to it than a worsening infection. The sudden decrease in bowel movements and the blood suggested some kind of obstruction.

Kraft palpated the abdominal wall, which looked perfectly normal. When he pressed down, he felt no significant tension or rigidity.

He breathed a little easier. It didn't seem to have progressed to the point where fluid was irritating the peritoneum. Perhaps it wasn't too serious.

Following a set pattern, he soon found evidence to support his theory: a mass in the lower-right abdomen that felt a bit like a sausage.

Things looked all right. Kraft's heart, which had been hanging in suspense, finally settled. It was probably intussusception, and given the location, he could safely guess that it was ileocecal intussusception.

At the junction of the small and large intestines, a section of the ileum at the ileocecal region had telescoped into the large intestine. One layer of intestinal wall had become several, blocking the passage completely. This wasn't uncommon in young children, whose intestinal function was easily disrupted, and it was one of the acute abdominal conditions pediatric surgeons dealt with most often.

The unlucky child might have had viral diarrhea, which itself was a risk factor for intussusception. Then she'd drunk some strange herbal concoction, and, naturally, developed intussusception.

The diagnosis had gone smoothly. Kraft felt a little like he did in case discussions, answering a teacher's questions: once he'd found all the evidence, he could confidently give his answer.

In theory, the next step was to confirm it with imaging. Unfortunately, there was no ultrasound here, and they couldn't take an abdominal X-ray with the patient standing. A definitive diagnosis was out of the question.

He covered the child with her clothes again, then picked up his pen and added a section at the bottom of the page for "Preliminary Diagnosis." In Norse, he combined the words for "intestine" and "telescope" and left a line beneath it.

Once he had time, he'd have to add an explanation below. Ever since becoming a lecturer, he'd had to leave space everywhere for definitions of terms. It was practically a professional habit now.

He looked up and explained to Gris, "You can think of it as one section of her intestine slipping into another and getting blocked. Do you remember when the pain started?"

"Just before the Clock Tower rang twice, I took her to the church. I can't remember the exact time."

That meant about an hour and a half to two hours ago. That was a blessing in disguise. They'd caught it early. Even with the detour to the church, there hadn't been enough time for the intestine to become necrotic. They could solve it without surgery.

So what was the nonsurgical treatment again?

"No, wait..." Kraft muttered. His heart, which had just settled, immediately started pounding again. It was like working through a difficult calculus problem smoothly until the very last step, only to get stuck—not because anything was wrong, but because he didn't have enough computational power to finish it.

"What's wrong?" Gris tensed up too. Kraft had just explained what was causing the problem, but now things seemed to have become complicated again. Nothing was worse than seeing the doctor's smile slowly fade.

Kraft didn't answer. A serious problem stood in his way, blocking the final step.

For a case like this, the standard answer he knew was an air enema. It could easily treat most early cases of acute intussusception like Lis's.

But that required the proper equipment. Kraft hadn't studied machine manufacturing. He had no idea how it controlled air pressure, pushing the intestine back into place without perforating it.

Even if he knew how to make one, could he just conjure up a machine with his bare hands? And even if the Church's God appeared on the spot and gave him one, how could he confirm that it had worked without ultrasound, X-rays, or other imaging?

An air enema wasn't an option. That left only the traditional method: Kraft would have to operate, putting little Lis through surgery and using a more invasive but direct and effective method to put the intestine back in place.

But if an air enema was impossible, how could surgery be feasible under these conditions? Operating without anesthesia or a sterile environment would be worse than praying for an angel from the Church to deliver an air enema machine.