New Worlds: Surgery

(This post is part of my Patreon-supported New Worlds series.)

It wasn’t long ago that the last thing you would want to do in the entire world was come under the knife of a surgeon.

Having been through multiple surgeries (I’ve managed to inflict a variety of joint injuries on myself over the years), I’m not going to claim they’re fun and games even now. General anaesthesia can be hazardous, and the recovery from a procedure can be long and tedious. But when I imagine going through that without the anaesthesia, and without antibiotics to stave off infection afterward . . . yikes doesn’t even come close.

In the grand scheme of medical history, most surgery is a very recent invention, because nobody even conceived of half of our routine procedures before the innovations that made them safer and less traumatizing, for patient and physician both. Never mind being the one on the table; imagine you’re the one holding the scalpel. Would you rather work on a patient who is screaming and thrashing, or one who’s lying insensate while you make your cuts?

(Some time ago I read a fascinating article which contrasted the adoption of antiseptic procedures and the adoption of anaesthesia, noting that the latter became standard much faster than the former. Why? Because antisepsis is a lot of work on the part of the doctor, and its benefits aren’t visible until days later, in the negative form of the infections that haven’t developed. But anaesthesia has an immediately obvious benefit which makes the doctor’s job easier. Of course they liked that one better.)

This doesn’t mean that surgery didn’t exist in the past, though. It did; its use was just limited to a small number of procedures, most of which were performed only in response to extreme need.

Oddly, the oldest procedure for which we have archaeological evidence is also one that sounds very extreme to people today: trepanation, the cutting of a hole in the skull. Modern doctors do this in order to get access to the brain for more advanced surgery (and usually call it craniotomy instead), but it also has a continuing role in relieving intracranial pressure, e.g. following a head injury. Trepanation also has spiritual and psychological connotations, as some groups believe it grants easier communion with the spirit world, or will help to release the “demons” causing mental problems or conditions like epilepsy. We can see archaeological evidence of this particular operation all the way back in pre-history, even with bone healing that shows the patient survived for years afterward.

Dental surgery goes back a long way, too, though I’ll save discussion of that for a future day when this series loops around to topics of personal care. Surprisingly, so does cataract surgery, mostly in the form of “couching” (which pushes the cataract out of the way), but in a few cases by the more modern technique of removing the affected lens entirely. In the previous discussion of childbirth we also talked about caesarean sections — though as I said then, the stories of mothers surviving that procedure seem mostly to be unsubstantiated myth until quite recently. Castration, on the other hand, had a much higher survival rate, and was used both to geld livestock and to create human eunuchs. And then there’s lithotomy, “cutting for the stone” (usually meaning a kidney stone). The old procedure involved going in via the perineum, which was so painful that Neal Stephenson writes convincingly in his Baroque Cycle of a character preferring to die from his kidney stone than let someone at him with a knife.

Trauma surgery, especially when done in response to battlefield injuries, was one of the largest categories. For a long time in Europe, surgery wasn’t the bailiwick of physicians (who didn’t want to sully their hands and their gentlemanly status with a trade so bloody and so prone to failure); instead it fell to a category of men called barber-surgeons, who were a standard attachment to military forces. These were exactly what it sounds like: barbers who also did surgery, on the grounds that they had sharp blades and good coordination. They were mostly trained through apprenticeship rather than formal education, and were very much the social inferiors of physicians.

Barber-surgeons on the battlefield were called upon to perform all kinds of trauma procedures like setting broken bones, reducing dislocations, removing arrowheads and shrapnel, cauterizing wounds, and most infamously, amputating limbs. That last was done as fast as possible, because the longer the patient was under the knife, the worse their chances. The English physician Robert Liston was famed for being able to perform an amputation in two and a half minutes — four times faster than the American Civil War surgeons who managed a respectable ten-minute procedure. (Though there’s also a story about Liston working so fast, he accidentally amputated his assistant’s fingers, and since both patient and assistant later died of sepsis and a witness reportedly died of shock, he holds the singular record of a 300% mortality rate for a single procedure. I haven’t been able to verify whether that’s true, but it would certainly make for a vivid anecdote in a novel!)

History does record more advanced procedures, including things like rhinoplasty (reshaping the nose) and operations on the brain. These accounts are mostly found in India, ancient Greece, and the Islamic world. Since references to them are fewer, though, and often credited to a single extraordinary practitioner like the Greek Galen, it’s hard for us to be certain how often they were performed, and how successful they may have been. Trepanation is easy to see; it leaves a very visible hole in the skull. Soft tissue operations, by contrast, leave little to no evidence in the archaeological record.

Even if a procedure was successful in its immediate aim, though, infection carried the ever-present specter of death. Just because you’ve removed the cataract or the kidney stone doesn’t mean the patient is going to survive and live a happy post-surgical life. Surgery in the pre-modern past was basically never routine, even when the operation was one the surgeon had performed a hundred times. You were always weighing the severity of the situation and the benefits a successful treatment would bring against the risk of death, then rolling the dice.

Give me modern medicine any day. Or better yet, futuristic procedures involving lasers and nanobots, which can address the problem without any incisions being required at all.

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About Marie Brennan

Marie Brennan is a former anthropologist and folklorist who shamelessly pillages her academic fields for inspiration. She recently misapplied her professors' hard work to the short novel Driftwood and Turning Darkness Into Light, a sequel to the Hugo Award-nominated Victorian adventure series The Memoirs of Lady Trent. She is the author of several other series, over sixty short stories, and the New Worlds series of worldbuilding guides; as half of M.A. Carrick, she has written The Mask of Mirrors, first in the Rook and Rose trilogy. For more information, visit swantower.com, Twitter @swan_tower, or her Patreon.

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New Worlds: Surgery — 3 Comments

  1. Pingback: New Worlds: Surgery - Swan Tower

  2. Before anesthesia, all operations were considered “extraordinary care” by the Catholic Church, and therefore it was always morally permissible to decide against one. (You were, after all, going to die someday of something.)