The Door Has Opened [2]
Even after closing Liston's custom-crafted bone flap, the operation did not instantly draw to a close.
Why?
Because it was only natural.
Wait, was it really natural?
Is closing it like this actually the right call…?
For the first time in an age, genuine doubt gripped me.
To tell the truth, in modern neurosurgery, unless the procedure was something exceptionally trivial—like a simple needle biopsy—surgeons almost invariably left a drainage tube embedded in the skull to monitor the surgical site.
Well, to be fair, certain pituitary adenomas and extra-axial tumors weren't strictly inside the cerebral hemisphere proper, so one might simply close up without a drain. Nowadays, surgeons mostly went through the transsphenoidal nasal route anyway, completely bypassing the need to crack open the cranium in the first place.
Even so, leave it open…? The skull…?
Suppose I inserted a tube into the cranium to relieve intracranial pressure and drain away any fresh blood if hemorrhage recurred. The intention was undeniably noble.
In fact, I shoved drains into abdominal cavities all the bloody time. Back in the modern era, they looked like hand grenades, so I had always called them "the grenade" instead of their proper clinical name. Now, karmic retribution was biting me right on the arse—I couldn't recall their formal medical designation for the life of me. Jackson-Pratt? Whatever.
In any case, what would happen if I somehow jerry-rigged one of those here—attaching a suction bulb to an intracranial tube?
"Good heavens… so that's another way a man can perish."
A hypothetical eulogy from Liston and his peers flashed unbidden across my mind. An intracranial infection would set in with absolute, mathematical certainty.
Which meant…
“Wait a moment.”
“Eh?”
Liston, who had been readying the suture needle, turned to look at me.
In the old days, such a thing would have been unthinkable—me delegating the closure to someone else. But now, it was entirely feasible. When put to the task, Liston possessed an uncanny, borderline miraculous knack for suturing. In truth, for this very operation, I had merely supplied the theoretical framework; it was no exaggeration to say that Liston had executed nearly the entire procedure with his own hands.
I had only made the skin incision. Liston had trephined the skull, and Liston had evacuated the hematoma. Without him, this surgery could never have been attempted in the first place.
“Let's take this… and leave it out when we close.”
“Leave this out…? Hold on, wouldn't that be disastrous?”
Liston stared at me with an utterly baffled expression. He blurted out the first words loudly before dropping to a conspiratorial whisper for the rest. Given that every stakeholder and curious observer was already packed cheek by jowl inside the operating theater, lowering his voice was an exercise in futility, but I matched his hushed tone nonetheless.
“His head was agonizingly painful because this pooled, stagnant blood was pressing against it, was it not?”
“Indeed. But haven't we cleared it all out? Surely putting things back where they belong is the proper course.”
Liston was correct. In surgical reconstruction, restoring anatomical structures to their pristine, original state was indeed the golden rule. Compared to his sound logic, what I was about to utter was, by nineteenth-century standards, complete and utter madness. I had sound physiological reasons, but through the lens of contemporary medical common sense, it sounded like pure barking.
“Now, think carefully. You of all people should know this best, my friend.”
“Generally speaking, there is little I do not know.”
There had been a brief, shining era when Liston was suitably humble. Back when I possessed all the knowledge and he possessed none, it was only natural. But his surgical talent was so wildly unhinged that, after taking on colossal roles like today's—roles where no man alive could substitute for him—his ego was swelling to monumental proportions once more.
Well, I was hardly in a position to scold him. At this stage, I genuinely could not function without Liston.
“When you beat a man bloody, what happens to him?”
“That depends entirely on the spirit in which I deliver the beating.”
“Right, of course. Let us assume you struck him half-heartedly, since a sincere blow from you would send him straight to the churchyard.”
“Ah… his bones would shatter.”
“And if you struck him just shy of breaking bone?”
“That isn't a beating. That is merely a fond pat. But very well, I am picturing it.”
“Right. Then his face, or whatever patch of flesh took the blow—it swells prodigiously, does it not?”
“It does… Ah. The brain swells as well?”
“Precisely.”
Look at him. He grasped a horribly crude analogy with terrifying, pinpoint precision. Considering he was a nineteenth-century butcher rather than a twenty-first-century clinician, it was staggering. Much of his contemporary world's medical canon was riddled with superstition, falsehood, and absurd humors, yet his fundamental cognitive faculties were so remarkably sharp.
“In essence, we have just delivered another severe beating to his brain. What do you suppose will happen if we seal it shut right now? It will swell up all over again on our account.”
“Aha. Oho… Hmmm. True, true… But can a man truly live without this… without this bone…?”
Liston looked down at the cranial lid. Thanks to his breathtaking mastery, the carved bone flap was a pristine, perfect circle. It wasn't overly massive, either. Had I wielded the trephine and saw, I likely would have splintered the margins, leaving behind an unsightly, jagged mess.
He can live without it.
Staring at that fragment of skull, I drifted into memories of my distant past. In a modern trauma center, the department one consulted most frequently was inevitably neurosurgery. While I had no intention of trivializing the visceral organs of the abdominal cavity as a general surgeon, when evaluating single organs in isolation, nothing rivaled the sheer fragility of the brain.
Back then, I had seen neurosurgeons excise cranial flaps far larger than this one for decompressive craniectomies, and the patients functioned just fine without them. Cosmetically, it was a bit jarring, but for a defect of this modest size, one would scarcely notice from the outside.
“Let us observe his progress, and if things look unfavorable, we can always fit it back in later.”
“Is that permissible? He is a Christian gentleman, not a stray mongrel.”
“It cannot be helped. Cerebral edema is entirely unavoidable.”
“Well… that does sound like sound reason, but still…”
Liston wore a look of profound astonishment. Yet after a brief pause, his pragmatic mind relented, and he nodded slowly.
“Aye, what choice do we have? It was his own fault for fracturing his skull. It certainly isn't ours, is it?”
It was a stroke of miraculous, self-serving logic, but I wasn't about to fault him for it. I was harboring the exact same sentiment.
Did I strike him over the head? Did I pour gin down his gullet? He brought it on himself with his drunken stupor.
“Quite right. Did we force the drink into his hand? A man ought to know his limits.”
“Indeed. Quite so. Let us proceed thus.”
United by our miraculous rationalization, we set the bone flap aside on the instrument tray. Of course, leaving the bone exposed to open air would dry out and damage the periosteal tissue, rendering it useless should we ever need to reimplant it. I turned toward Joseph.
“Immerse this in normal saline.”
“Pardon? Wait, sir? In… in that?”
The boy’s sheer shock was entirely warranted. At this point in history, sterile normal saline was practically worth its weight in liquid gold. One had to distill the water repeatedly, calibrate the precise salinity, and somehow preserve it from microbial spoilage without a modern refrigerator. In an era without refrigeration, maintaining its sterility was a monstrous headache.
Truth be told, whether it actually stays unspoiled is anyone's guess.
Precisely because of that uncertainty, Joseph bore the grueling responsibility of preparing small batches every single week and discarding the surplus. Its sole clinical use was intravenous fluid resuscitation for patients dangling over the precipice of death. We hadn't even administered it to today's patient, which spoke volumes about how jealously it was guarded. Demanding that he submerge a loose scrap of bone in such a precious elixir was bound to stun him.
“We may have to set it back in place later. Until then, it must remain immersed.”
“B-But why, Master?”
Judging by his wide eyes, he was not merely shocked; an earnest curiosity was burning within him. It was understandable. In fact, compared to blindly obeying, harboring such scientific curiosity was thoroughly rational. I could have offered a completely sound, academic dissertation on osmolarity and tissue viability.
Alas, this was the nineteenth century.
I cast my gaze skyward for a brief, theatrical moment.
“Joseph.”
I called his name in a voice dripping with solemn, divine reverence. I wasn't attempting to feign spiritual possession; it simply felt appropriate for the occasion.
“Y-Yes, Master?”
“What is normal saline?”
“Uh… pardon?”
“What manner of liquid is it, that you guard it with such obsessive devotion?”
“Ah… it is a fluid resembling the sacred humors of the human body…”
“Indeed. And the taste was calibrated by our very own sommelier, was it not? So its authenticity is beyond reproach.”
These poor lads genuinely believed the tonic's salinity had been perfected through the refined palate of a wine taster. In reality, I had simply measured out the correct chemical concentrations myself. But how on earth was I supposed to explain the metric milliosmoles of isotonic saline to men who still believed foul air carried cholera? I had learned long ago that playing the Joseon savant card or invoking the Lord had its hard limits. Thus, we had roped in a sommelier under the guise of taste-testing. Regardless.
“Yes, Master.”
“Is that bone not a living part of the human form?”
“It is.”
“In its natural state, it rested enveloped in the sacred fluids of life. Therefore, must it not be cradled in the fluid that most closely mirrors our earthly essence if it is to endure?”
“Ah… Ahh…”
“Is that not the sublime providence of the Almighty?”
“A-Amen.”
I watched Joseph scurry off to fetch the saline, muttering a string of breathless amens under his breath. Feeling a sudden prickle of heat at the back of my neck, I glanced behind me to find Liston gazing in my direction, his weathered face filled with pious awe.
People already whispered that I was some manner of demigod or shaman. A stray pang of dread crossed my mind—at this rate, was I going to end up as the high priest of a deranged medical cult?
“Now then, let us close the scalp.”
“Ah, aye. Shall I…?”
“Yes, my friend. Your hands have acquired marvelous grace.”
“You flatter me. Heh-heh.”
Be that as it may, an operation had to be brought to its conclusion. And frankly, even if I did become a cult leader, what of it? It wasn't as if I intended to bilk the gullible or commit atrocities; I was simply healing the sick. In fact, founding a religious sect might well prove advantageous. A shadowy medical cult deeply entrenched with the imperial aristocracy and political elite? Why, that sounded practically invincible.
Perhaps I ought to give it some serious thought.
A doctrine built entirely on the premise of Solo Leveling via Divine Medical Revelation. Of course, the true esoteric dogma was The Trauma Surgeon Conceals His Regression, but since that was a secret no mortal soul could ever discover, the divine revelation narrative worked far better on the surface.
Snip. Pull.
While my mind wandered down these utterly unhinged avenues, Liston proceeded with the closure, his stitches steady, diligent, and silent. Watching him work was a genuine pleasure. The man truly possessed golden hands. To think that a fellow of such exquisite dexterity had spent decades doing nothing more than hacking off limbs in under thirty seconds… The tragic constraints of an unenlightened era felt terrifyingly acute once again.
“Alfred.”
Seeing that the final sutures were nearing completion, I called out to Alfred. Despite not participating directly at the operating table—a role that naturally induced crushing drowsiness—Alfred had remained locked in a state of absolute, hyper-focused concentration. At the sound of his name, he gave a crisp nod and began adjusting the ether vapor valve with breathtaking finesse.
“Mmmgh…”
As a result, the very instant the last knot was tied and Joseph swabbed the incision clean, the patient began to stir.
“Phew.”
“Whew…”
Starting with myself, a collective sigh of profound relief swept through every medical officer present. Listening closely, I could hear the Hospital Director standing at the back of the gallery releasing a hearty exhale of his own.
It was only natural. Brain surgery. Cracking open a man's skull in the nineteenth century. When I first awoke in this wretched era, such a feat had been utterly beyond the wildest realms of imagination.
“My head… it hurts…”
There was no time to indulge in sentimental nostalgia. I responded immediately to the patient's groggy murmur.
The assistants had already ferried him from the operating theater into a private recovery room. Calling it a private room was a bit generous; in an era devoid of electronic monitors, the room featured a massive glass window that allowed the staff to peer inside from virtually anywhere in the hospital corridor. Privacy could go hang itself. A man being slightly embarrassed or inconvenienced was vastly preferable to him dying unobserved.
“We have made a considerable incision in your scalp, sir, so pain is to be expected. But I suspect it feels entirely different from before, does it not?”
“Ah… Indeed. It is sharp now. But that suffocating, heavy pressure from before… it is gone.”
“That is because the operation was a resounding success.”
“Th-Thank you…”
“Direct your gratitude to Mr. Liston. I merely offered the conceptual guidance; he was the one who performed the surgical miracle.”
“I-Is that so? As expected… of the Sword Saint…”
“You are far too kind, sir.”
I wasn't entirely certain whether referring to a surgeon as the 'Sword Saint' was an appropriate medical compliment, nor was I sure whether Liston ought to look so smug upon hearing it. Regardless, as I watched the heartwarming exchange unfold before me, a single, pressing priority crystallized in my mind.
Blood pressure… Right. I need to find a way to measure blood pressure.