Obstetrics & Gynecology (Part 4)
Professor Blundell had insisted that they were all going to die anyway, but to my eyes, that cynical pronouncement was nothing more than an emotional defense mechanism.
How many deaths had he been forced to witness in this godforsaken hospital over the years? If Blundell had truly been a cold, callous bastard, the carnage wouldn't have bothered him in the slightest, nor would he have spent his evenings running around London with the likes of us.
"Let us try just a little more," Blundell rasped. "At least before the tissue decays any further."
Blundell had agonized over the clinical determination of death far more than any of his contemporaries. While he may not have been the original inventor of the rust bell designed to prevent premature burial, he was among the first physicians to champion its introduction to London, which was remarkable in its own right. And then, of course, there was his work on blood transfusion—though whether those early trials truly deserved the name remained open to debate. Even so, he was a man who had rolled up his own sleeve and drawn his own blood without hesitation simply to pull a dying patient back from the brink.
"Professor, I really cannot… not any more…" Colin groaned weakly.
"Nonsense, lad! Do you think opportunities like this come by every day?"
For all his grumbling about inevitable fatalities, look at him now. Dawn was already breaking through the high, grimy windows of the dissecting room. Joseph and Alfred had long since collapsed into stupors of sheer exhaustion, and even Colin, who was stubbornness personified, was shaking his head in defeat. Yet Blundell was still standing over the slab, bathed in sweat, his hands moving ceaselessly.
As for the surgical results… well. For a training exercise, it was barely passable, but in truth, that was only to be expected. In fact, given the tools and the era, it was downright miraculous.
The difference is, I already know the answer key.
Human memory is a strange and fickle thing. When I was sitting at my desk earlier, my mind had been an absolute blank, to the point where I genuinely wondered if I had ever learned anything about a Cesarean Section during my modern medical training. Obstetrics was never my specialty, after all. But the moment I stepped into the dissecting room and stood before a pregnant cadaver, the surgical incisions sprang to the front of my mind as if guided by instinct.
That alone had been startling enough, but the physical repetition of the procedure dredged up even deeper theoretical knowledge. Since most of what I retained hailed from my med-school lectures, the academic history surfaced first.
Cesarean sections only barely found their footing as an accepted procedure in the late nineteenth century. Even then, saving both mother and child was extraordinarily rare.
For centuries, the grim operational doctrine had been simple: save the infant, at the cost of the mother's life. Most mothers would have pleaded for that very outcome anyway. Maternal instinct takes root from the moment of conception, after all. As a bachelor who had never even managed to get married, let alone father a child, that depth of devotion belonged to an emotional realm I could scarcely fathom. Regardless, I had no intention of repeating the bloody trial-and-error of medical history.
The best suture material we have on hand right now is silk. And silk…
Silk sutures had vanished from modern operating theaters, or at least had been relegated to extreme niches, for very good reasons. Price and supply chains played a part, of course, but the overriding factor that made synthetic polyamides standard was infection control. Braided silk acts like a wick for lethal bacteria.
We have to perform a Cesarean hysterectomy. It's the only viable course in this era. Caring about future fertility is an impossible luxury right now.
There was a clear reason why, even after abdominal surgery had become technically feasible, we still mostly limited ourselves to appendectomies. Amputating an organ and tying off the stump was one thing; trying to reconstruct an existing, vascular organ while leaving behind countless foreign silk threads inside the peritoneal cavity was another entirely. The infection risk wasn't just higher—it was on a completely different plane of danger.
Working from that principle, I pondered the method of incision. In the twenty-first century, surgeons predominantly used a low transverse Pfannenstiel incision placed well down along the pubic hairline. I had attempted to replicate it on the cadaver earlier.
"Pyeong, what on earth is that?" Joseph had asked, blinking groggily.
"Uh… nothing. Don't worry about it."
It hadn't worked. I prided myself on having dexterous surgical hands, but that low transverse approach required modern retractors, lighting, and specialized exposure. Some brilliant pioneer in the future would refine it to minimize scarring while maximizing visual access, but for now, I had to concede that it was beyond our present setup.
In the end, I decided to adopt the long vertical incision Blundell had used earlier. As for the uterus itself?
If our plan is to excise the uterus entirely, the incision across it can be as wide as we like.
We could slice it open in a bold cross shape if we wished. That would yield an immense surgical field, allowing us not only to extract the infant swiftly and safely, but also to observe the placement of the placenta, the uterine anatomy, and the vascular distribution with absolute clarity. Once positive clinical experience and empirical data accumulated, progress would accelerate. We would refine the technique decades ahead of the original timeline. Blundell was a dedicated professor, after all, and the assistants and surgeons surrounding him were men of exceptional passion.
"So this is the final form you envision," Blundell remarked, inspecting the specimen.
"Yes, sir."
I ligated the uterine vessels feeding the organ and resected it cleanly, taking care to leave the ovaries behind. My modern instinct was to preserve the patient's female endocrine function, but naturally, Blundell's brow furrowed.
"Why leave these behind?"
I couldn't give him the real answer on the spot. How could I start rambling about estrogen and endocrine pathways? In this era, the biological reason why Sir James wore a false beard remained a complete mystery, just as no one could explain why castrated men never suffered from male pattern baldness. Hormones were an uncharted continent.
If I tell him I left them behind on a whim, it'll sound absurdly unprofessional.
Yet I couldn't just brush it off either. It wasn't merely my reputation at stake. If these nineteenth-century butchers decided that thoroughness meant scooping out every last reproductive structure, what would happen to the surviving patients? Worse, rumors might spread that excising the womb stripped a woman of her feminine nature, leading superstitious doctors to abandon the lifesaving hysterectomy altogether. In fact, that was almost guaranteed to happen. Victorian medicine was rife with men who were timid where they ought to be bold, and terrifyingly reckless where they ought to be cautious.
"Lord in Heaven," I muttered under my breath, preparing my soul to tell a shameless lie. Or rather, it wasn't a lie—it was a pious truth I chose to adopt on the spot.
"Eh? What are you praying for all of a sudden?"
Blundell stared at me as if I had lost my wits. Fortunately, Colin was already slumped in a wooden chair, nodding off, and Liston had retired to bed hours ago. Formidable though Liston's stamina was, he had an endless roster of amputations and abdominal operations scheduled for the morning and needed whatever sleep he could scrounge.
"Though we are excising an organ bestowed by the Almighty to preserve the mother's life… surely it is our Christian duty to minimize what we desecrate, is it not?"
"Doesn't that contradict what you said just a moment ago about carving away without hesitation?"
"Not in the slightest, Professor. We remove the womb because leaving it invites corruption and death, yet we spare the rest to honor the life God granted. There is no contradiction."
"Is that so?"
Blundell was an expert in stubborn perseverance, but even giants crumbled after an all-nighter. His exhausted mind was visibly drifting.
"Indeed, sir. Besides, who knows what vital purpose the Almighty assigned to those small glands? To remove them without cause would be hubris."
"Well… that is true enough, I suppose."
"If there is no reason to touch them, we ought to leave them be."
"Quite right. Hmm. Quite right."
He nodded slowly in a daze of sheer fatigue. Having successfully muddied the waters, I picked up a piece of scrap paper and rapidly sketched out our surgical protocol. My drawing was crude, but every anatomical landmark was clearly delineated—accurate enough that no licensed physician could possibly mistake the intent. In short: a long vertical abdominal midline incision, a cruciate opening of the uterus, complete resection of the uterine body, and preservation of the ovaries.
I had assumed that once the protocol was established, we would rush straight into an actual operation that very night. But reality didn't cooperate. It wasn't for a lack of laboring women, nor because the patients were in fine health.
"Should we not attempt it on that woman over there?"
I pointed toward a mother who had been in agonizing labor for over ten hours. Judging by the ghastly pallor of her face, she was already halfway into the grave. But Blundell shook his head vehemently.
"No. We must reserve this only for those who are on the very verge of death."
"Then what about the women who died earlier?"
As I noted before, the Obstetrics & Gynecology Annex consisted of two separate wards, each containing four twenty-bed rooms. Ward 1 was attended primarily by physicians, while Ward 2 was run by midwives. That was the extent of my prior knowledge. Under normal circumstances, a medical student would have spent months rotating through the service to learn its inner workings, but I had leapfrogged straight into a professorship alongside Robert Liston in the surgical department. Today was the first time I had witnessed the ward's daily machinery firsthand.
"Who died?" Blundell asked blankly.
One might wonder how on earth a physician could ask who had died in his own ward, but after observing the chaos throughout the day, the question made grim sense. Three mothers had perished in Ward 1 today alone. In Ward 2, another two had succumbed.
"Five women have died today, Professor."
"Ah… but that cannot be helped, Pyeong. Such collapses are impossible to foresee. I would have to be standing right at their bedside at the exact moment their life begins to slip away, and that is simply impossible."
It sounded like an appalling thing for a doctor to utter, but in all honesty, I couldn't fault him. To predict a catastrophic collapse, one needed vital signs. But did we possess a proper Mercury Sphygmomanometer? An electrocardiogram? A pulse oximeter? Listing them off only made me realize how utterly naked we were. How could we establish surgical indications under such conditions?
The entire definition of an operative indication is broken from the ground up.
Come to think of it, we diagnosed appendicitis in much the same crude fashion. We would visit Semmel's consulting room, palpate the patient's abdomen before they died under Semmel's tender care, and slice them open if the signs pointed to a ruptured appendix. But an inflamed appendix offered a relatively generous golden hour; even if the diagnosis lagged by a few hours, the patient could occasionally hold on. Obstructed labor did not afford such grace. In cases of severe dystocia, unless we detected the mechanical obstruction beforehand through pelvic examination, there was simply no way to intervene in time.
Throwing a tantrum wouldn't conjure blood pressure cuffs out of thin air. We had to alter our diagnostic approach.
"Let us think through this systematically, Professor."
"Think through what?"
"Why does a woman fail to deliver a child?"
"Because she is weak."
"Uh…"
Well, yes. Physical frailty played a part. No, wait—what was I thinking? Had I lost my mind?
"Aside from that, sir."
"What other reason could there be? A physician's calling is to aid the weak."
"I mean a medical reason, Professor. A mechanical, anatomical reason."
"Medically?"
"Yes."
"Medically speaking… because she is weaker than other women."
I felt an overwhelming urge to punch him in the jaw.
"Whoa, steady on," Blundell muttered, recoiling slightly.
"What is it, sir?"
"For a moment there, you looked precisely like Robert Liston."
"I assure you, I did not."
"No, you had that exact murderous glint in your eyes! But at any rate… ah, yes. If the birth canal is too narrow, delivery becomes impossible. Indeed, a contracted pelvis invariably results in obstructed labor."
Violence really was an effective educational tool. Just contemplating it had produced the correct clinical answer. Had I actually struck him, he might have deduced the entire etiology of dystocia on the spot.
"Why are you staring at me like that? You are terrifying me, lad."
"Nothing, sir. What else?"
"Hmm… ah! Blast it, yes. A patient of mine died not long ago because the babe presented feet first. The poor creature became wedged halfway through the canal, and there was simply no way to extract it."
Breech presentation. The human cranium is disproportionately large compared to other mammals, and in an infant, the head is larger than the rest of the torso. For a safe delivery, the baby had to descend cephalic-first, turning head-down well before labor commenced. A breech presentation meant the head remained lodged at the top of the uterus when contractions began. Even in the twenty-first century, managing a breech delivery was an obstetrician's nightmare.
"Isn't there a way to detect that condition beforehand?" I pressed.
"Beforehand? Well… yes, by palpating the maternal abdomen. If the head is situated above, the fundus of the stomach feels notably firm and round."
"Exactly! So when we encounter such a case, shouldn't we proceed directly to a Cesarean section?"
"Is that so?"
What do you mean, 'is that so'?!
Suppressing the urge to bellow at the top of my lungs, I took a deep breath and kept my voice level.
"In all your years of practice, Professor, has a full breech delivery ever ended well for both mother and child?"
"Never."
"There is your answer."
"By Jove… you are right. Yes, in such cases, we ought to act beforehand. Hmm. If memory serves, we have one such case in the ward today."
"Then what are we waiting for? Let's go!"
"Right! Yes, let us go at once!"