Obstetrics, Part 3
Lord, I found myself praying for the first time in an age.
Why? Because... to tell the truth, I knew next to nothing about obstetrics.
To lump it together under general surgery simply because it involved a scalpel was absurd; obstetrics was one of the five foundational pillars of medicine. The gulf between surgery and obstetrics was as vast as the divide between internal medicine and psychiatry. And yet...
"Allow me to demonstrate first," Blundell offered.
"By all means, Professor."
At this moment in time, James Blundell was the most preeminent obstetrician in the room. In truth, even if his renown did not quite match Liston's legendary stature, he was a celebrated master whose reputation echoed through every corner of London.
"Now, observe closely. Thanks to Taepyeong's insistence on antisepsis, we can afford to be bold when opening the abdomen."
"Understood, sir."
With a wet, tearing sound, Blundell drew his blade across the flesh. Because the cadaver had already begun to decay slightly, the knife cleaved through with unnerving ease. Slicing vertically made the cut smoother still.
"In the past, some practitioners made a cruciform incision, carving a cross into the belly," Blundell explained, "but that routinely killed the patient. Hence, we employ the Liston method: a clean vertical slice."
"Yes, Professor."
A vertical cut... Yes, vertical was certainly leagues better than carving a holy cross into an open wound. Carving a crucifix onto someone's belly was just... unsettling. Protesting against a cross incision in nineteenth-century Britain felt like asking to be branded a blasphemer, but even so, it was sheer madness.
God, look how long he’s slicing it.
In the twenty-first century, a Cesarean section was performed with a horizontal incision, not a vertical one. While I couldn't recall every nuance of modern obstetrics, I knew the Pfannenstiel incision was designed primarily to minimize scarring, neatly hidden along the bikini line. Furthermore, considering the anatomy and position of the uterus, an incision made low on the lower abdomen was more than sufficient, allowing for an intervention in an area far less visible.
Anyone who paid attention in basic biology would picture it: the uterus sits nestled deep in the pelvis, wider horizontally than it is tall. While gestation naturally forces the uterus upward, its fundamental anatomy doesn't vanish—its horizontal diameter remains far broader than its vertical span.
Even if he chooses a vertical cut, there's no reason on earth to start at the xiphoid process. Of course, if surgical exposure was your sole concern, slashing wide and deep gave the clearest view. Blundell had drawn a monstrous vertical canyon straight from the tip of the solar plexus down to the pubic hairline, slicing straight through the peritoneum and prying the abdominal walls apart. It was a colossal incision. Opening someone like a gutted fish certainly gave ample room to extract an infant. The fatal snag was obvious: the mother is almost guaranteed to die.
Blood. A massive incision inherently multiplied the hemorrhage. On top of that, the risk of lethal infection surged exponentially. Even with our obsessive, psychotic hand-scrubbing and carbolic dousings, we couldn't sterilize the smoggy London air. To make matters worse, the metallurgical quality of our crude iron instruments inspired little faith.
"Ahem. This here is the uterus," Blundell murmured, pointing with his forceps.
"And what is this?" asked one of my disciples.
"That is the bladder."
"Ah."
Unperturbed by the gory spectacle, Blundell pressed on. Neither Liston nor my apprentices possessed much familiarity with the peritoneal cavity, let alone the internal anatomy of a woman, which sparked an earnest debate. To put it simply, from anterior to posterior in the female lower pelvis: bladder, uterus, and rectum. In the lower abdomen, at least; higher up was a different matter entirely.
"First, we retract the bladder to the side..."
In truth, during an actual Cesarean section, there was hardly any need to aggressively push the bladder aside like that. In a full-term pregnancy, the dramatically expanded uterus balloons far above the bladder. You didn't even need macrosomia to see why—stuffing a two-to-three-kilogram infant inside a woman's belly expanded the organ to monstrous proportions. A low transverse incision directly into the lower uterine segment was enough to pull the baby out.
"Now, here lies our greatest dilemma," Blundell paused, frowning.
This was where the venerable obstetrician hit a wall. Given how frequently dead mothers were brought to autopsy slabs, he certainly didn't lack anatomical knowledge. Puerperal fever—that cursed plague of the lying-in wards—had claimed uncounted thousands of women over the centuries. While our own hospital had dramatically reduced maternal mortality thanks to antisepsis, that was a recent miracle; for decades prior, mothers had perished in droves. A veteran of Blundell's tenure knew the architecture of the maternal womb like the back of his hand.
"If we incise the uterus vertically, hmph, one would expect the child to present itself clearly, yet in practice, it proves exceedingly difficult."
"It looks fairly straightforward from here, though?" Joseph chimed in.
"Hah!"
Blundell clicked his tongue, turning toward Joseph. But unlike Joseph's usual knack for driving people mad with eccentric carbolic acid fanaticism, Blundell's rebuke was founded upon clinical truth.
"There is something known as amniotic fluid," Blundell explained patiently. "The sack is filled to bursting with it. Now, what do you imagine happens the instant the womb is split like that?"
"Ah..."
Exactly: gallons of amniotic fluid would flood straight into the peritoneal cavity. A layman might wonder what harm a little water could do, but in this godforsaken era, surgical suction did not exist. I suppose I could have handed hollow reeds to my iron-willed medical disciples and commanded them to suck it all out, but there was another grim reality to contend with: meconium. Fetal shit, in plain English. What would happen if foul fluid tainted with fecal matter washed over the exposed viscera? In an era where our sole defense was the fungal lottery of penicillium-molded bread, peritonitis meant guaranteed, agonizing death. Why had we bribed constables and scavenged corpses from the slums in the first place? To save mothers, not to consign them to rot from the inside out.
"We should incise horizontally," I proposed.
Though my memories were hazy, I seemed to recall the attending surgeons doing just that during my clinical rotations in medical school.
"Horizontally, you say...?" Blundell mused.
"Yes. If we make a transverse cut right at this lower segment to deliver the child, and draw the wound upward to prevent the fluid from spilling into the cavity, what then?"
"Ah..."
"Even if you applied traction vertically, the exposed surface area would be far narrower, limiting control."
Did I actually know all the biomechanics of uterine musculature? Hell if I did. But modern medicine didn't switch to transverse uterine incisions for fashion. There was inevitably a sound, evidence-based reason developed over centuries, paid for by mountains of maternal corpses.
"Is that so? It does sound plausible," Blundell stroked his chin, "yet another problem remains."
"Which is...?" I asked, genuinely curious.
London was a swarming anthill of human souls, and among them, the impoverished working class numbered in the hundreds of thousands. When labor went wrong, many of them were dragged into charity hospitals. People in the modern world might wonder how destitute paupers could afford a hospital, but 'poor' in Victorian London usually meant day laborers and factory hands; they had a few pennies to their name, just never enough to eat properly. Consequently, Blundell had seen an astronomical volume of deliveries. In terms of raw numbers of laboring women laid out before him, even a top obstetrician from twenty-first-century Seoul couldn't begin to hold a candle to him.
"Look here," Blundell pointed out. "If we slit the uterus vertically, it is far easier to close with sutures. A horizontal wound offers no such convenience."
"Mmm..."
He had a point. Suture approximation along a longitudinal plane was generally much simpler in bilateral human anatomy, and the muscular fibers of the uterus were no exception. If one had god-tier needlework, it might not matter, but...
The suture material...
Our equipment was the real nightmare. Forget the old adage about a master never blaming his tools—that was utter rubbish! Tools were everything in surgery. When it came to keeping someone from bleeding out, cutting corners on materials was criminal.
Leaving our crude, septic thread inside the abdominal cavity of an exhausted, postpartum mother... knotted into a crudely stitched uterus?
A chill crept down my spine. That wasn't surgery; it was a deferred death sentence.
"Do we really have to leave the uterus behind?" I asked.
As far as I knew, performing a Cesarean hysterectomy—removing the uterus right after delivery—was a recognized, lifesaving surgical maneuver. Few laymen knew this, but in a modern university hospital, there were only two departments that could barge into an operating room without anesthesia clearance, screaming that a patient was crashing. One was obstetrics. The other? The severe trauma center. Barring trauma thugs, obstetrics was the sole king of catastrophic bleeding. The reason was dead simple: when things went south, both mother and child were dead in minutes, and the torrent of blood pouring from a ruptured or atonic uterus was enough to make even hardened general surgeons turn pale.
"Eh?"
I shrugged nonchalantly. So long as the ovaries were preserved, the endocrine system would remain intact. Aside from permanent sterility, a successful hysterectomy wouldn't pose any grave hormonal complications.
"I'm asking if we shouldn't simply excise the uterus entirely."
"What madness are you spouting?! How on earth is a woman supposed to live without her womb?!"
"Indeed, Taepyeong! To cast away an organ bestowed by God Almighty at our own whim—how can you even utter such sacrilege?!"
The backlash was instantaneous and fierce.
Right... I forgot which century I was in.
Yes, yes, God had bestowed it, hadn't He? But shouldn't keeping the damn patient alive take precedence? This wasn't filial piety Confucianism where every hair and fingernail was sacred—why leave behind a tick-tocking death trap that would inevitably turn gangrenous?
"Granted, the Almighty bestowed it... but think for a moment," I pressed.
In the past, the mere mention of God would have made me back off immediately for fear of being burned at the stake as a sorcerer. But not anymore. The men gathered in this room were at least willing to listen to my logic, no matter how wild it sounded.
"If we sew it shut and leave it inside... you all know our current suture thread is practically a breeding ground for miasma, don't you?"
"Mmm."
"Which is why we must soak the thread in mercury—"
"Shut your mouth, Joseph."
"Yes, Boss."
Having thoroughly crushed Joseph's interjection, I continued. "You've all seen the fibers under the microscope."
"We have..."
"Can we truly afford to abandon this much tainted material deep inside an open abdomen?"
"Hmm... Is that so? But don't we already leave ligatures behind in other operations?"
Yes, we did leave them behind. We had no other choice when tying off severed arteries. When on earth were nylon and Vicryl going to be invented?
"And every single time we do, all we can do is pray," I retorted.
"Hah! And the Lord answers all prayers, does He not?" Liston boomed solemnly.
"Is that why your hairline is receding further back every day, elder brother? ...Ah. Did I say that out loud?"
Wait. Did I actually say that out loud instead of thinking it?
In an instant, I found myself staring into the eyes of a demon—a paradoxical demon who whispered prayers to the Lord.
"Lord in heaven... receive another soul today..." Liston muttered darkly, reaching for a bone saw.
"Restrain yourself, Liston!" Blundell shrieked.
"Spare my life, brother!"
I dropped to my knees without hesitation. Jesus Christ. I'd already reincarnated once; I wasn't about to die a second time over a bald joke! Dying was bad enough, but what if my next reincarnation flung me into the Dark Ages in the body of an Asian man?
"No, your hair isn't thinning at all, brother! You have a majestic mane!" I pleaded desperately.
"He's right, Professor Liston. It is Professor Blundell who lacks hair," Joseph added helpfully.
"Why must my scalp be dragged into this?!" Blundell sputtered in outrage.
"Are you implying elder brother is the one going bald, then?!" I snapped back at Joseph.
"No, no, heaven forbid!"
Exchanging frantic glances with Blundell, I scrambled to soothe Liston's ruffled ego. Blundell nervously tugged at his sparse locks, his eyes growing misty.
"Look at this, my hair is coming out in clumps..." Blundell lamented.
"Indeed, indeed. Whew," Liston exhaled, stroking his temple. "You gave me quite the fright. As if Robert Liston could ever fall prey to baldness."
"Of course not! How could the Lion of Surgery lose his mane? It is as thick as a beast's coat!"
"Aye, quite so. Quite so."
Once Liston had calmed down, I carefully steered the conversation back to the matter at hand.
"At any rate... it is my firm recommendation that we excise the uterus entirely."
"Mmm..."
Liston, a man so devout that he murmured prayers to the Lord even before amputating a limb in under thirty seconds, could hardly bring himself to agree on the spot. But his hesitation hardly mattered. The man directing obstetrics here was Blundell.
"Well, it makes little difference either way," Blundell remarked with a shrug. "They almost always die regardless."
The real problem was that the preeminent obstetrician of the British Empire was casually dropping lines like that.