Medicine

A surgical theater in Forgegate's Medical District. The bellows is driven by clockwork; the assistant watches the patient.

Medicine is the best thing the Known World does, and it is not close. Everything else in this chapter runs into a ceiling. Medicine runs into nearly nothing: nine hundred years of physicians and apothecaries have worked at it without once finding a wall, and what they have built is a practice a person from a comparable age in our own world would find implausible.

Why medicine runs free

Medicine is the one field in the Known World that has run at its own pace for nine centuries, and it shows. Sterile technique, anaesthesia, chest surgery, a real chemistry of treatment — against a world with no generator anywhere.

Hidden truth — not known in Teraell

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Nothing in medicine builds a weapon. A surgeon who can graft a vein cannot invade anybody, and unlike steam, electricity or industry there is no step from the one to the other. So medicine was never on the list, and nothing has ever interfered with it. See What Is Blocked and How.

They know what infection is

The microscopes are good enough to resolve a cell and the things smaller than cells that live alongside them. So the Known World has known for centuries that wounds turn because organisms get into them, that those organisms can be seen, cultured, and identified, and that heat and cleanliness kill them. Everything follows: steam sterilization of instruments and dressings, surgeons who wash, clean districts built for the purpose (which Clearhold laid out deliberately and everyone else copied), wards kept in a state a visitor finds slightly oppressive. None of it is instinct or tradition.

What the apothecaries have

Anesthesia from Hwysra spores and a controlled paralytic from Nyfra sap — every patient who lies still through an operation and wakes remembering none of it owes that to two plants that would kill a person where they grow. The Known World has never had the fast-butcher tradition, because a surgeon has always had as long as the work takes. Difference engines calculate dosages and blends, which is why a preparation made in Eldershore behaves the same as one made in Forgegate. And the cultures: a living medicine that clears infection out of a wound, grown and propagated by division, the single most consequential thing anybody has ever produced. An infected wound can be treated rather than watched; childbirth is survivable in a way it was not in any comparable age of ours; a man who takes a bad cut four days from anywhere still has a decent chance. Every city grows its own. Everybody would rather have Eldershore's.

Blood

Typing and transfusion, from the same microscope that gave them germ theory: mix one person's serum with another's cells and watch whether they clump. Spring-driven centrifuges, cold cabinets, and anticoagulants that are ordinary chemistry. A surgeon can replace what a patient loses, which is the difference between an operation and a death, and the change that opened up everything below.

Keeping blood

Blood will not keep. Citrated and cold it lasts days rather than weeks, and the chemistry that would hold it longer needs cold this world cannot reach — a cold cabinet is a cold cabinet, and nothing in it approaches what deep freezing would want. There is no stock sitting on a shelf anywhere.

What every city has instead is a register. Donors are typed in advance and their types and addresses are written down, and when a surgeon needs blood a runner goes and fetches the person. Large houses, the guilds, the Watch and the fleets all keep their own lists, and a man on one is sent for at any hour and goes.

Being on the register is ordinary rather than remarkable. The world does not make a performance of it and nobody is thanked publicly for turning up, which a stranger reads as coldness and a Teraellan reads as the point: a thing you said you would do is a thing you do, and announcing it would be Mlaedi.

Giving fluid

A needle in a vein, a length of rubber, and a glass vessel on a stand high enough that gravity does the rest. No pump, so the rate is set by a screw clamp and watched by somebody counting drops in a glass chamber. Salt solutions for shock and dehydration, and the anaesthetist's drugs by the same route in a theatre.

It is one of the plainest machines in any hospital in the world and one of the ones that saves the most people.

Surgery

Good anesthesia, a reliable paralytic, transfusion, sterile practice, antibiotic cultures, Glaera silk for thread, and clockwork instruments from the finest makers in the world. Amputation and bone-setting. Abdominal surgery. Cesarean section that mother and child survive. Tumors that can be reached. Lithotomy. The appendix as a routine operation. And chests: opening one collapses the lung, so a sealed airway and a bellows keep it inflated, the bellows driven by clockwork or a small steam plant because a man squeezing one for a Spaen squeezes it badly by the end — and an assistant whose whole job is watching the patient stands at it, because the machine cannot notice anything.

Vessels

Where the Known World quietly excels, because none of the obstacles are electrical. Fine consistent thread, good clamps, magnification, anticoagulation, and a technique for sewing a vessel end to end without narrowing it — Glaera silk, clockwork clamps precisely tensioned, loupes and a compound microscope, solved chemistry, and triangulation worked out long ago by somebody whose name is on it. Repairing a severed artery is ordinary work in any city with a surgical tradition, and so is grafting a vein around a blocked vessel or a temporary shunt to keep a limb alive.

The heart

Cardiac surgery exists, is the hardest thing anybody does, and nobody calls the results reliable. A stab wound can be sewn on a beating heart; a constricting sac cut away; a fused valve opened by feel through a small incision while the heart goes on beating. Grafting a coronary vessel — about a Threid across, on something that moves — can be done on a beating heart with a clockwork stabilizer quieting a patch of muscle long enough for one anastomosis; one graft is realistic, two is ambitious, and it is a reputation rather than a routine. For a still, empty heart the circulation must be taken over: by a pump-oxygenator — governed roller pumps, a surface across which blood takes up air, temperature control — of which there are single digits in the world, each a commission and no two alike; or by cross-circulation, a living donor of matching type whose heart carries both circulations. It works, and it is the only operation where two people can die. The donor is nearly always kin. With circulation supported the heart is stopped, cooled, opened, sewn, and persuaded to start again by massage or, if it will not, by a single discharge from a bank of charged globes. One or two grafts; clots, air, and incomplete repair are common; the mortality is frank. None of it needs a generator — the obstacles are vessel size, blood handling, and a clock that runs out in about a third of a Spaen.

Looking inside

The endoscope is a tube, a lens train, and a small Kwaenith at the end — the whole reason the instrument works, since every other light burns, smokes, or goes out. Magic-lantern projection puts what the surgeon sees on a wall, and surgical theaters are built around it. Radiography exists in the larger hospitals of every city: a charge machine of two insulated glass discs turned in opposite directions by a small steam engine, throwing charge into a glass tube where it becomes something that passes through flesh and not bone, with a photographic plate beneath. It shows bone and anything dense that should not be there and nothing of soft tissue; the tubes are delicate and the apparatus does not travel, and a physician in a Roedhaven has never seen one.

What nobody can see

Solid tissue through intact skin. Contrast extends the plate to spaces — the gut when a patient swallows a suspension, vessels when something is injected, the ventricles when air is introduced — but liver, brain, muscle, and kidney are much the same to a plate, and no chemistry solves it; seeing soft tissue through a closed body needs a different physical principle, and every one of them needs a generator. So the world asks the body other questions: it reads the outside of an organ by palpation, percussion, and auscultation, nine centuries of it recorded in Clearhold's archive; it measures what an organ does, which is where the effort went once imaging stalled; it looks at what can be reached with an endoscope or a biopsy; and it reads displacement, knowing a tumor by what it has pushed aside. What remains is opening somebody up to find out, and every surgeon in the Known World has done it and found nothing, and lost a patient by waiting too long to ask.

Who is best at what

The one field where no city leads outright. Eldershore has the pharmacology — plants, cultures, climate, and the harbor. Clearhold has the archive, the cleanest hospitals, and a precision in dosing the other cities treat as excessive and copy anyway. Forgegate has the surgery: the theaters, the instruments, the Glaera-silk thread, and the surgeons who open chests. Shining Reach has the Academy, the teaching, and psychiatric care that is the best in the world with no competition. Stormharbor has the limbs — crush injuries, severed hands, cold water — and fits and designs more prosthetics than anywhere. The Iron Coves has whoever is available.

What it costs

Care is tiered by station and wealth. Shining Reach has clean hospitals for the wealthy and public clinics with solid care for everyone else; Forgegate emphasizes what gets a man back to work; Clearhold documents and treats to a standard; Eldershore distributes medicines through lineage networks as much as markets; Stormharbor is rugged and practical; the Coves is whatever can be paid for. A slave's medicine is her owner's expense and obligation; see Health, Injury, and Correction.

Age and vanity

Accepting one's own appearance is the norm and is held seriously. Cosmetic surgery is disdained, and the line is what the person wanted from it: removing skin because it chafes is treatment, removing it for how it looks is something else; a face rebuilt after a burn is care, the same work on an unburned face is a man asking a surgeon to help him lie about what he is. Fighting age out of vanity is read as weakness. Shining Reach argues about it more than anywhere, and its working position is that clothing is chosen and a body is given. A slave is the one case judged differently and only halfway: her owner cannot order work on her body and can ask, and if she agrees the world is gentler, because her appearance is part of her service rather than a claim about who she is.

See also

• Prosthetics · Living Long · Dangerous Fauna and Flora#What is taken from them · Difference Engines · The Trades