The Boss's Surgery (Part 3)

Paying people to let us operate on them...

Quite a diabolical concept, wasn't it?

Try pulling a stunt like this in the twenty-first century, and... Wait, wouldn't they? They run clinical trials all the time, don't they? Aside from practicing raw surgical technique, modern medicine does just about everything else.

I had briefly worried I might end up dragged away in irons, but upon deeper reflection, perhaps it wasn't so scandalous after all. The intention behind it was what truly mattered. Was I doing this to chase earthly riches and renown? Granted, once a surgeon became a living legend, colossal wealth was bound to follow. In fact, I was already raking in a tidy sum. Yet my ultimate ambition lay elsewhere entirely. I possessed no real interest in money.

'Anyone who claims to have no interest in money is utterly obsessed with it.'

The cynical quip of a famous Korean exam tutor suddenly drifted through my mind, but I brushed it aside.

"Quite a ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠crowd has gathered," I remarked, looking out.

"Bound to happen," Robert Liston replied, leaning against the doorframe. "I hear some desperate souls were even contemplating lopping off their own noses just to qualify."

"Good heavens, absolutely not. That cannot be allowed."

"Endure a single day of misery in exchange for an entire month's wages—who among them wouldn't jump at the chance?"

In any case, my modest plan had simply been to use our pooled capital to practice one reconstruction per day. Yet within twenty-four hours of our announcement, over twenty applicants had swarmed our doorstep. Naturally, had the hospital merely put out a sign saying, 'Step right up, patients welcome,' we never would have seen numbers like this.

This miraculous turnout was courtesy of the Hospital Director and the London Police Chief. They had plastered our recruitment notices across the foulest depths of the East End slums—wretched alleys ordinary citizens couldn't ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠set foot in without an armed retinue. Unsurprisingly, the vast majority of the men huddling outside were denizens of those very rookeries. To them, a month's wages in hard coin was nothing short of a fortune.

"I suppose that makes sense," I murmured.

"Aye. These are folk who haven't the faintest idea whether they will live to see tomorrow. Or even survive through the afternoon, for that matter."

"Right. Thinking of it that way certainly puts my conscience at ease."

"As though your conscience ever bothered you before," Liston scoffed.

"Well, that's..."

I opened my mouth to shoot back a witty retort, but the words withered in my throat. Liston had pointed a thick thumb toward our private cellar—specifically, the sommelier's quarters.

Inside sat the prisoner I had locked away.

A poor wretch confined solely to taste human urine for diabetes diagnostics... Truly, I had no choice in the matter. The man's palate was an extraordinary gift from the heavens! He could distinguish the subtlest variations in glucose sweetness with terrifying precision. With just a few more weeks of training, I felt certain he could estimate specific gravity and concentration by tongue alone.

"Shall we proceed with the surgery, then?" I asked, clearing my throat.

"Aye. But tell me, why are you insisting on excluding those who lost their noses to the French pox?"

"If a man has already lost his nose once to tertiary syphilis, wouldn't the chances of the graft rotting away a second time be vastly higher?"

"Ah... would it?"

"Most likely. Though that's merely my own working hypothesis."

"Well, hypothesis or not, coming from your lips it sounds terribly plausible. There is no sense in courting needless failure. Still..."

"Still what?"

"Can we trust these beggars' words entirely? How are we to know whether it was syphilis or an honest street blade purely on their say-so?"

"Ah... there is a way."

"Is there?"

Of course there was. Why wouldn't there be?

Strip them bare.

While diagnosing primary or latent syphilis might prove tricky without serological tests, once a man's infection had progressed far enough to rot the nasal cartilage straight off his skull, the telltale systemic signs—gummata, chancres, cutaneous rashes—were unmistakable. A single visual inspection would lay the truth bare. And if any case remained dubious? Well, nothing could be done about that. I was a trauma surgeon, not God Almighty; how could I catch every occult pathogen?

"Right then, let us inspect the candidates."

We began triaging the gathered throng. Calling it an 'interview' was far too generous; our examination focused strictly on three parameters: whether their physical constitutions could endure the surgical trauma, whether stripping back their filthy rags revealed active venereal lesions, and whether they possessed sufficient forehead tissue to flap downward. Smooth speech and noble spirit were entirely irrelevant. What purpose did an eloquent tongue serve when strapped unconscious to an operating table? While weeding out visibly volatile madmen was sensible, destitute wretches from the slums possessed zero legal or social recourse against an establishment hospital in Victorian Britain anyway. Furthermore, we were hardly ordinary practitioners; we had an entire dockside street gang answering to our beck and call, rendering any prospective retaliation an utter impossibility.

"These four will do nicely," I decided after inspecting the lot.

"Four?" Liston mused, stroking his jaw. "Shouldn't we take on more?"

"A handful of successful cases to refine the protocol is plenty. The real question is whether harvesting the costal cartilage will take. Can an unvascularized cartilage graft survive beneath the flap?"

"Mm... that is precisely what we are here to discover."

In truth, vascular pedicle connection wasn't necessary for cartilage grafts. That was an established biological fact in the twenty-first century, and I had plenty of clinical experience to back it up. Nasal framework tissues were remarkably hardy, far tougher than laymen imagined. Modern plastic surgeons shoved silicone, Gore-Tex, and all manner of synthetic foreign bodies into noses without major catastrophe in most cases. Naturally, overreaching—packing in an oversized strut to force an unnatural bridge—could cause pressure necrosis and skin breakdown. But that was a luxury problem that had nothing to do with crude reconstructive repair. Perhaps if Victorian society ever advanced toward elective aesthetic rhinoplasty, that might become a concern, but for now, restoring basic anatomy was triumph enough.

"We'll start with this gentleman first," I said, pointing to a gaunt laborer.

"Very well."

"Assuming he doesn't have other pressing matters to attend to, of course."

"What other engagements could a destitute vagrant possibly have?" Liston snorted. "Have you seen the legions of unemployed pacing the gutters these days?"

"Ah, is it truly that severe?"

"You truly are born of the high aristocracy through and through, aren't you, lad? Look upon the plight of the common rabble once in a while."

"I... understood."

I summoned our chosen candidate into the prep room. Predictably, the poor wretch swore on his mother's grave that he had nothing else in the world to do. Aside from bowing repeatedly, all he could babble about was the coin.

"The money your lordship promised... you will truly pay it...?"

"Yes, yes. You shall receive every farthing."

"You swear it upon the Holy Cross...?"

"You will have it, I assure you."

His relentless badgering grew tiresome enough to test my patience. And yet, what could one expect? It laid bare just how terrifyingly desperate the man was. And it was that very desperation that brought him beneath our knives today.

"Alfred."

By now, our surgical theater had established an impressively disciplined routine. Granted, when measured against twenty-first-century standards—the rudimentary operating table, crude metal instrument stands, and erratic gas lamps—there were still plenty of glaring shortcomings. But compared to the butcher shops of early nineteenth-century London, conditions had improved beyond recognition.

"Yes, Master!" Alfred answered briskly.

"Prepare induction."

"Right away!"

The anesthesia apparatus alone was a marvel of our handiwork. Previously, when the brass valve clicked and spun, no one could tell what angle it had turned. One literally had to gauge the vapor flow by the faint hissing sound of pressurized gas. Now, things were different. With the reservoir topped off, calibrated markings engraved along the dial indicated the exact degree of rotation. While it might not ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠provide an absolute volumetric dosage in milliliters, it allowed us to maintain consistent relative concentrations.

Thus, a standardized protocol was gradually taking shape: thirty degrees per half-hour for lighter patients, forty-five degrees for heavier builds. Of course, it was far from an exact science, but my benchmark for progress was always the barbaric past.

Hsssssssh.

Alfred turned the dial to forty-five degrees and sealed the fitted leather mask over the patient's face. Thanks to the micro-perforations now drilled around the rim, there was no longer any need to repeatedly clamp and pull the mask away to prevent suffocation. Naturally, pressing it down indefinitely would still asphyxiate the poor bastard, but within our team, such blunders were no longer a concern. All thanks to Alfred.

The boy kept his other hand pressed firmly against the patient's radial artery, monitoring the pulse with furrowed brows.

Teach them one thing, and at least they retain it properly now.

In the beginning, whenever I tried to teach these Victorian apprentices a modern concept, they would spatter ten varieties of medieval nonsense and send my blood pressure soaring. Now look at them. Was this transformation not nothing short of medical rebirth? A proud chuckle slipped past my lips before I could suppress it.

"You haven't been sneaking a draft of the ether yourself, have you?" Liston muttered, eyeing me suspiciously.

"Certainly not, Boss."

What an absurd accusation. Did he take me for some degenerate addict who would succumb to anesthetic vapor on the job? The sheer cheek of it...

"Antisepsis," I called out.

"Understood!"

Now that the patient was properly sedated, it was time for surgical scrubbing. For sites like the abdomen or thorax, scrubbing prior to induction was standard practice to minimize the duration of general anesthesia. But when operating on the face, disinfecting post-anesthesia was vastly superior.

How did we discover this vital piece of wisdom?

"Fuck... stop! In God's name, stop it, please!"

We learned courtesy of Colin. When carbolic acid was swabbed across his bare, conscious face during an earlier demonstration, the poor aristocrat writhed in unholy agony. Truth be told, even as I painted the solution on him, the thought had crossed my mind: Ah, this is downright sadistic. This must burn like liquid hellfire, sting to the bone, and taste foul enough to invert the stomach.

Scrub, scrub.

Through trial and error, we had perfected the division of labor. The chest wall for rib harvesting was scrubbed clean ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠beforehand, while the facial antisepsis commenced the instant the anesthetic firmly took hold.

Say what you will, but Joseph's disinfection technique is a masterwork in its own right...

Joseph scrubbed with the terrifying zeal of an inquisitor cleansing heresy. Provide him with superior chemical agents, and the boy would sterilize an entire operating wing without breaking a sweat. The only tragedy was that neither at present nor for decades to come would the world synthesize an antiseptic superior to the crude carbolic solutions we currently commanded.

"Scrubbing complete," Joseph announced, stepping back with dripping hands.

"Good. Joseph, take the ribs with the Boss."

"Right."

"Colin, to my side."

"Yes, sir!"

Minimizing anesthetic exposure was now treated as sacred gospel within our surgical theater. Even Liston, who initially sneered at time constraints under gas, had fully embraced the rule. His reasoning was brutally straightforward.

"Blast it all... and it was such a magnificent amputation."

Liston's speed at severing limbs had grown sharper than ever. 'Inhuman' was the only word that did it justice. Excluding modern microsurgical reconstruction, I doubted a single surgeon in the twenty-first century could sever and tie off a thigh with the blinding velocity of Robert Liston. And yet, patients still expired on his table. Not from hemorrhage, but from the anesthetic itself.

It was likely attributable to idiosyncratic host variations—severe malignant hyperthermia or anaphylactoid collapse...

The exact same chemical that served as a merciful blessing for one man could act as an instant, virulent poison to another. That was elementary pathophysiology in the modern era, but complete heresy in the 1840s. And I had no desire to stomp out the fragile, tender shoot of scientific skepticism that had barely begun to take root in their Victorian minds.

Future medical historians seemed all too likely to slap that patronizing verdict across my legacy. It couldn't be helped. Whatever comfortable academics sitting in twenty-first-century lecture halls chose to babble, my duty was to keep the living, breathing human beings right before my eyes from turning into corpses. And to accomplish that, I had to whip this motley crew into people who could play the part of true surgeons, whatever dark compromises it required.

"Scalpel," I commanded.

"Scalpel," Colin echoed, slapping the steel firmly into my palm.

While I swept away my wandering thoughts, the operation commenced in earnest. Colin and I stood flanked at the patient's head, while Liston and Joseph manned the exposed right thorax.

Sssrrk.

My proficiency with harvesting a forehead paramedian flap had developed to the point where incising and mobilizing the frontalis muscle felt entirely instinctive. Fluid, confident strokes traced the planned template. Furthermore, having pre-selected the patient based on his cranial structure and forehead laxity, there was ample tissue to rotate downward without excessive tension.

"Right... will this suffice?" Liston called out.

The senior surgeon proved that his grueling drills had borne fruit. Though his previous rehearsals had been conducted exclusively on fresh cadavers, he excised a segment of rib in the blink of an eye. Or rather, costal cartilage, to be precise. At any rate, the harvested strut was pristine.

"Yes. Drill a single fixation channel right here, please."

"Stand aside."

With an awl-like bone punch, Liston tapped swift, decisive perforations into the remnant nasal bone where the original cartilage had rotted away. In a modern operating room, an electric surgical drill with saline irrigation would have been standard. Yet Robert Liston was an absolute force of nature. His raw physical power and mechanical finesse were so exquisitely balanced that he punched clean, uniform suture channels through cortical bone with eerie precision, without splintering a single millimeter of the fragile surrounding nasal bridge.

"Done," Liston grunted, wiping his brow with his forearm. "Satisfied?"

"Perfect."

The chest team immediately transitioned to closing the thoracic incision. Meanwhile, Colin and I busily anchored the carved costal cartilage strut to the remnant nasal stump and draped the vascularized forehead flap across the newly fashioned framework. Phrased aloud, it sounded like an impossibly delicate reconstructive feat. But with Liston having already punched the anchoring channels and neither I nor the patient expecting a sculpted marble masterpiece, the fixation proceeded with remarkable speed.

What truly mattered, however, lay in the days ahead.

How would this newly grafted tissue integrate into the host bed? Would the ischemic cartilage survive, or would secondary bacterial infection rot the flap from the inside out?

As anyone with clinical insight could tell, there was very little more we could physically do with nineteenth-century technology to guarantee graft survival. This held true not only for this man, but for the other three candidates awaiting their turn. And so, for the weeks that followed, the hospital wards echoed with the ceaseless, desperate murmurs of devout prayers, transforming our surgical wing into something resembling a fanatical revivalist prayer hall.