Cesarean Section (Part 3)
Let me review the indications for a Cesarean section.
The most common scenario that came to mind was cephalopelvic disproportion—a pelvis structurally too narrow for delivery—yet in truth, such cases were remarkably rare. Even among mothers who had previously undergone a Cesarean, roughly two-thirds were still capable of delivering vaginally. This patient, Duke Jamie's granddaughter-in-law, did not appear to possess an abnormally narrow pelvis either.
Which meant I had to consider other causes.
With neither ultrasound nor modern diagnostics at hand, the fetal position was about all I could ascertain.
Uterine inertia will have to be deduced from the elapsed time. Placenta previa, from hemorrhage... though if bleeding has reached that point, she's practically dead already.
Fetal heart rate? I couldn't even monitor the mother's vitals in real time, so how on earth was I supposed to measure the pulse of a child still inside the womb? Every passing moment drove home the stark reality that modern medicine had only advanced because countless other technological fields leaped forward alongside it.
In any case, organizing these thoughts in my head, I finally stepped before the patient. Blundell, who had arrived earlier, handed me chlorinated lime and soap.
"As civilized human beings, let's at least wash our hands with soap."
When I first arrived in this era, I had honestly believed soap simply did not exist in this wretched world—because not a single soul ever used it. Yet to my utter astonishment, it existed in abundance! Granted, it was I who had introduced chlorinated lime as shock therapy...
"Isn't chlorinated lime far too painful? Soap would be so much better."
Humans are creatures of habit: force them through an agonizing ordeal first, and when you present an easier alternative, they will gladly embrace it—even if that 'easy' alternative is still objectively a nuisance. That had been my entire psychological gambit. And yet...
"Then we shall scrub with soap and chlorinated lime."
Wait, what? Didn't these bastards detest washing with every fiber of their being?
The cholera outbreak must have left too deep a scar, because matters had taken a bizarre turn. Somehow, the handwashing ritual had grown increasingly elaborate with each passing day. Worse still, everyone I knew had mobilized into sanitary watchdogs. Look at them right now: the fellows who had accompanied Blundell—Alfred, Joseph, and Colin—were all staring intently at my hands.
"Urgh."
Swallowing bitter tears, I scrubbed with soap, scrubbed again with chlorinated lime, pulled on rubber gloves, and then drenched those gloves in chlorinated lime and carbolic acid. The surrounding air reeked so violently of caustic chemicals, stinging my flesh so fiercely, that it felt like an absolute crime if anything remained unclean.
"The cervix hasn't dilated beyond an inch. It has already been... eight hours in this state. Look at her."
"Uuuugh..."
Those agonizing minutes hadn't been completely wasted, however. Handwashing took so damn long that we had learned to adapt out of practical necessity; Blundell had chattered away the entire time I was scrubbing.
"In my experience, when it stalls like this... I sent for you at the seventh hour, yet there has still been no progress."
One inch. 2.54 centimeters. What a maddeningly vague measurement.
Even after living in Britain for well over a decade, I still couldn't get used to imperial units. How this nation managed to build the British Empire while clinging to such atrocious measurements defied all logic. It wasn't as if the Englishmen I met were extraordinarily brilliant either. I suppose there had to be geniuses somewhere directing the fleet to invade other countries and carve out colonies, but still...
"Hmm."
Setting my musings aside, I conducted an examination myself. Indeed... roughly one inch. No further dilation.
"Could you try pushing for me?"
"N-no more... I can't..."
"Just once more, please."
"Urrgh!"
The exhausted patient strained with every ounce of her remaining strength at Duke Jamie's nod. This was purely subjective, but although she was clearly straining, I felt virtually no downward pressure. She was thoroughly depleted. Or, worse, suffering from complete uterine inertia.
This is bad. At this rate, she won't survive.
Whether Blundell read my expression or remembered his own earlier examination, his face twisted into a grimace of despair as he spoke. He was right. Left like this, they would die—both mother and child.
One might wonder why childbirth was so easily fatal, but examining the physical ordeal an infant endured during delivery revealed just how harrowing it was. To emerge into the world, the fetus had to navigate the narrow birth canal through agonizing contortions of its head and body. To conform to the pelvic contours, the infant's head rotated ninety degrees, followed by another ninety-degree twist to free the shoulders.
"Let's do it," I said under my breath.
"Do it? Truly?"
"Didn't you summon me here to operate?"
"Well, yes, but... this is..."
Was there a difference between a death where the corpse remained intact and one where it did not? To a physician, death was death, but to the grieving family, the disparity was immense. It inevitably bred remorse: If only we had done nothing...
Of course, in the nineteenth century, death lurked around every corner, so a patient expiring on the operating table rarely resulted in legal consequences for the surgeon. But the client was Duke Jamie.
"I am frankly terrified," Blundell muttered. "Word has it he became quite vicious after having his balls cut off."
It wasn't simply because Jamie was a grand peer of the realm. Even his closest friend, Sir Damien, reportedly found him difficult to deal with these days. And that hadn't come from hearsay—Sir Damien had told me himself. Not that I couldn't understand. Losing one's manhood would do that to anyone.
There were even whispers that Butcher Harry had been subjected to horrific private torture before being executed—or rather, murdered—without anything resembling a proper trial. So yes, his venom was entirely understandable.
"Still, we have no choice," I whispered back. "If we do nothing, she dies."
Besides... I had Sir Damien in my corner. I was confident he would shield me at least once. And if he couldn't? I could always flee to France. Those baguette-munching bastards might be even more uncivilized, but I had no shortage of French aristocrats who owed me their lives.
"Bloody hell. Performing a Cesarean section on a highborn lady... I knew I shouldn't have chosen obstetrics."
"Think of the reward if we succeed, though."
"It would be extraordinary, no doubt. In truth, I wasn't their first choice either."
Blundell's gaze shifted toward the midwives huddled in the corner. Honestly speaking, when it came to natural childbirth, those women were vastly more capable than me—and perhaps even Blundell. Paradoxically enough... I didn't actually know how to deliver a baby vaginally.
Back in modern medical school, I had watched professors induce labor through various means, but despite obstetrics and gynecology being a core major clinical discipline, what medical students actually learned during clerkships was pitifully meager compared to general surgery or internal medicine. By sheer volume of student training, it might as well have been a minor specialty.
"Those midwives have already warned Duke Jamie about the likelihood of her death."
"We must deliver our warning as well."
"I... suppose we must?"
"We have to. He needs to hear it plainly."
Regardless, the grave risks had to be communicated. Signaling my master assistants with a flick of my eyes to prepare for surgery, I walked straight over to Duke Jamie.
In the brief time since I last looked, he had attached a fake mustache, but the craftsmanship was so clumsy that he would have looked far better without it. Is he testing me? A loyalty test or something? The ancient Chinese adage of pointing at a deer and calling it a horse popped into my mind. Comparing Duke Jamie to the eunuch Zhao Gao was...
Wait, neither of them has balls. No, no, stop!
Damn it, I almost burst out laughing. Being suspected of laughing at his fake mustache would get me executed, but if he realized I was laughing because I likened him to an imperial eunuch, I was a dead man for sure.
"Ahem."
"So... what is her condition?" Duke Jamie asked, anxiety thinning his voice to its natural post-castration pitch.
To think benign prostatic hyperplasia had subjected a proud duke to such a butchering. It was truly tragic. Looking at his pathetic state almost brought tears to my eyes.
"It is very poor, Your Grace. The probability of her passing is extremely high."
"B-but you are a brilliant physician, aren't you? Eh? Word has spread among all who know... they say you are even more capable than Liston these days."
"Who on earth told you such a thing?"
"The hospital director."
"Ah."
Right. That old rascal was more than capable of spouting such nonsense. What on earth was the relationship between those two? How could the director act so irreverently without getting thrashed by a duke? And to think he was gossiping behind my back as well.
"Regardless, I will do everything in my power."
"Yes, yes. Please, proceed at once."
"We must operate."
"An operation... So it has come to that after all. What are the chances my granddaughter-in-law survives?"
At this moment, it was impossible to laugh at his ridiculous mustache. The man before me was the patriarch of a noble house, and a member of his lineage was dying. There was only one response to offer in times like this.
"I shall do my utmost, Your Grace."
"I see..."
What meaning did percentages and statistics truly hold? In research, perhaps, but to a patient and their kin, it was strictly binary—zero or one. Life or death.
"Right."
Having finished the consultation, I returned to find the surgical preparations complete. The patient had been given an explanation as well, so she didn't seem particularly alarmed despite having her abdomen abruptly bared to the room. Well... even if she wanted to panic, she lacked the strength to resist.
"Do not worry too much, my lady," I said, offering reassurance while giving Alfred a nod.
Alfred nodded back and turned the gas valve, already pressing a crude rubber mask over the patient's nose and mouth. He uncanny rhythmically applied and lifted the mask in synchrony with her breathing—a feat no twenty-first-century anesthesiologist could replicate. Without the raw, fearless nineteenth-century instinct, such a gamble was impossible; modern faint-hearts would suffer cardiac arrest from pure anxiety.
Hiss.
With the rush of gas, the woman's head slumped limply to the side.
Is this safe?
I had no idea. All I knew for certain was that the patient from yesterday was still breathing, and her baby was alive as well. Yesterday's procedure had taken under an hour from opening to final closure...
"Scalpel."
We had disinfected the skin while she was still conscious. Carbolic acid smelled pungent and stung like hell, but since general anesthesia carried such lethal unpredictability, there was no choice. To minimize the duration of sedation, every preparatory step had to be taken beforehand.
Sliiice.
Drawing the blade, I incised the patient's abdomen. I had hesitated for a fleeting second over whether to make the incision slightly shorter than yesterday's, but dismissed the thought.
A breech presentation would have been preferable. Too much time has already been lost.
There would be bleeding. Uterine contractions didn't merely push the baby out; they also compressed the vasculature, stemming hemorrhage. With labor stalled for this long, what would happen? If I played around with a smaller cut and lost visibility, only for the mother to bleed out, how could I bear the guilt? Scars be damned—keeping her alive came first.
Sliiice.
I laid open a generous, wide incision, just as I had yesterday.
"Good heavens!"
"Lord have mercy..."
The midwives standing by to assist with catching the infant gasped in horror. It was a miracle neither of them fainted on the spot. Slicing open a living abdomen had been a sacred taboo for centuries. Yet obstetrics was the one field that had occasionally crossed that line in the past; and because those desperate attempts took place before the dawn of antisepsis and anesthesia, the midwives and obstetricians were the ones who had witnessed the most gruesome butcheries. Decades of collective trauma were surely resurfacing in their minds.
"Hnghh..."
One didn't need past memories to feel sickened by the spectacle. Duke Jamie was shuddering violently. And his son beside him? The young lord was already slumped against the wall, clutching his hands in desperate prayer. It was a chaotic, distressing scene, but there was no helping it.
Lord above.
Even I was silently praying. The exposed uterus looked alarmingly different from yesterday's.
Please, let her live.
A desperate plea burst from the depths of my soul.